The nurse is sitting with a client diagnosed as having schizophrenia, disorganized type, who starts to
laugh uncontrollably, although the nurse has not said anything funny. The nurse should say
a. "Please share the joke with me.".
b. "Why are you laughing?"
c. "I don't think I said anything funny.".
d. "You're laughing. Tell me what's happening.".
D
The client is likely laughing in response to inner stimuli such as hallucinations or fantasy. Moller
suggests focusing on the hallucinatory clue (the client's laughter) and eliciting the client's
observation. The other options are less useful in eliciting a response. Option A: No joke may be
involved. Option B: "Why" questions are difficult to answer. Option C: The client is probably not
focusing on what the nurse said in the first place.
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The nurse is collaborating with the dietitian and a patient with hypertension to plan dietary modifications. These modifications should include which of the following?
A) Reduced intake of protein and carbohydrates B) Increased intake of calcium and vitamin D C) Reduced intake of fat and sodium D) Increased intake of potassium, vitamin B12 and vitamin D
The client has received an injection of a local anesthetic temporarily rendering of a portion of the body insensible to pain. This is an example of:
a. general anesthesia c. regional anesthetic b. medical anesthetic d. supportive anesthesia
The patient with jaundice has a nursing diagnosis for impaired skin integrity to:
1. sedate the patient. 2. apply mittens or socks to hands. 3. restrain hands. 4. distract with conversation.
The nurse notices that a client has difficulty moving their head. Which cranial nerve should the nurse assess?
A. VI. B. IX. C. XI. D. X.