A client, aged 16 years, comes to the crisis clinic with several superficial cuts on her left wrist. She
paces around the room and cries with convulsive sobs.
She cowers when approached and responds to
the nurse's questions with shrugs or monosyllables. After a few minutes spent with the nurse, the
client is slightly calmer. To assess the client's perception of the precipitating event, the nurse should
ask
a. "Why are you crying?"
b. "Why did you injure your wrist?"
c. "How can I help you feel more comfortable?"
d. "What was happening just before you started to feel this way?"
D
A clear definition of the immediate problem provides the best opportunity to find a solution. Asking
about recent upsetting events permits assessment of the precipitating event. Options A and B use a
poor communication technique, asking a "why" question. Option C asks the client to make a
decision that should be made by the nurse after assessment is completed.
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During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take?
A) Assist the patient to the bathroom. B) Offer the patient a bedpan or urinal. C) Wait until the patient gets to the operating room and is catheterized. D) Have the patient go to the bathroom.
A patient with acute mania has exhausted staff by noon after joking, manipulating, and insulting all morning. Staff members feel defensive and fatigued. Select the best action
a. Call the health care provider to evaluate the patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Seclude the patient, and then call the health care provider to write an order. d. Explain to the patient that the behavior is unacceptable. Ask the patient to be more cooperative.
The nurse is caring for an older adult who is prescribed digoxin. When assessing for the signs and symptoms of digoxin toxicity, the nurse would expect to see which of the following? (Select all that apply.)
a. nausea e. cardiac dysrhythmias b. shaking f. confusion c. incontinence g. halos around lights d. constipation
To assess vibratory sensation, where should the nurse place the vibrating tuning fork?
1) On a tendon 2) On a bony prominence 3) On a muscle 4) On a dermatome