The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client's plan of care?
a. Administer a sedative medication.
b. Ask a family member to stay with the client.
c. Use restraints to prevent the client from falling.
d. Place the client in a wheelchair at the nurses' station.
B
Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls.
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A 17-year-old male has been diagnosed with osteosarcoma of the upper tibia following several months of leg pain. Which of the following statements by the client demonstrates that he has an accurate understanding of his diagnosis?
A) "I guess it's good that at least my tumor's a benign type." B) "I'm really nervous about having to get surgery and chemo." C) "I'm gaining hope from the fact that it's really rare for someone to die from this." D) "It still feels surreal that I'm going to have to get my leg amputated."
During the assessment of a client's respiratory system, the nurse determines that the client's expiration phase is the same length as the inspiration phase. The client's respiratory rate is 14 per minute
The nurse would document this finding as: 1. obstructive breathing. 2. bradypnea. 3. respiratory distress. 4. normal.
After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which of the following findings should lead the nurse to believe the child is experiencing anxiety?
a) Not able to get comfortable. b) Frequent requests for someone to stay in the room. c) Inability to remember her exact address. d) Verbalization of a feeling of tightness in her chest.
The female client has a fungal infection and will receive nystatin (Mycostatin). What assessment data is critical for the nurse to review prior to administering this medication?
1. The type of diet the client is eating 2. The amount of fat in the client's diet 3. Whether the patient could be pregnant 4. The client's height and weight