The nurse in interviewing a client observes changing of position frequently, wringing hands, and laughing at inappropriate times. Which of the following would be appropriate for the nurse to include in the assessment based on this information?
1. Anxiety assessment
2. Mental status testing
3. Attention deficit testing
4. Nutrition assessment
1
Rationale 1: Body language and verbal responses can be key indicators of anxiety. If the patient exhibits anxiety during the interview, it may be a reflection of anxiety related to the situation or a need for further assessment.
Rationale 2: Mental status testing would be indicated if the client demonstrates confusion.
Rationale 3: The nurse does not conduct attention deficit testing. This is beyond the nurse's scope of practice.
Rationale 4: The observations by the nurse do not provide clues to the client's nutritional state.
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The purpose of an organization's philosophy is to:
a. influence the goals and objectives of an organization. b. display how the parts of an organization are connected. c. be an instrument that gives voice to the organization's mission. d. serve as the institutional framework that shapes the direction of knowledge and skill acquisition.
Which actions could meet the definition of a quasi-intentional tort in a long-term care facility?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A resident wanders away from the facility and is found 2 miles away. 2. The resident is restrained to a chair in the day room to prevent wandering. 3. The local newspaper publishes pictures of residents enjoying a holiday presentation by children. 4. The nursing assistant slaps a resident's hand when the resident pinches another resident. 5. The nursing home provides a list of names and clothing sizes to a local group who wishes to purchase birthday gifts for residents.
The nurses in a clinic are discussing studies in hormone replacement therapy (HRT)
After reading the Heart and Estrogen/Progestin Replacement Study (HERS), one nurse asks another, "What do you think the most important finding of HERS was?" The nurse would be correct to state that the most important finding was a. HRT had no effect on the heart and the risk of MI. b. the risk of a first MI was not affected by HRT, but secondary prevention was evident. c. HRT prevented a first MI. d. the risk of MI increased in the first few years of HRT.
A patient who has recently begun taking carbamazepine (Tegretol) for bipolar disorder reports having vertigo and headaches. Which action by the nurse is appropriate?
a. Ask the provider whether another medication can be used for this patient, because the patient is showing signs of toxicity. b. Contact the provider to request a complete blood count (CBC) to evaluate for other, more serious side effects. c. Reassure the patient that these effects occur early in treatment and will resolve over time. d. Review the patient's chart for cytochrome P450 enzymes to see whether an increased dose is needed.