A person was abducted and raped at gunpoint. The nurse observes this victim is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the patient's level of anxiety?
a. Weak
b. Mild
c. Moderate
d. Severe
ANS: D
Anxiety is the result of a personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. "Weak" is not a level of anxiety. Mild and moderate levels of anxiety allow the patient to function at a higher level.
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A client being treated for cancer has a tumor designation of Stage IV, T4, N3, M1. What does this staging indicate to the nurse?
A) The tumor will respond to chemotherapy. B) The tumor is small in size. C) The tumor has metastasized with lymph node involvement. D) There is one single tumor to treat.
In the first few hours the mother should be encouraged to spend time holding, touching and breastfeeding the baby as this increases levels of oxytocin and prolactin. What do these hormones do?
a. They help keep the baby warm and help the mother fall in love with the baby. b. They keep the father relaxed and calm, and help establish breastfeeding. c. They keep the mother relaxed, increase tolerance, reduce stress and stimulate natural hormonal analgesia. d. They are involved in tolerance and adaptation, reduce stress levels and keep both the father and the baby calm.
The restraint should always be the correct ____________________ to fit the patient.
Fill in the blank(s) with the appropriate word(s).
An appropriate method for assessing a client's respirations is for the nurse to:
A. Place the bed flat B. Remove all supplemental oxygen sources C. Explain to the client that the respirations are being assessed D. Relax and gently place the client's hand over the upper abdomen