A depressed patient shares with the nurse that he, "has been thinking about ending it all". Based on NANDA recommendations, the nurse:
a. Implements suicide precautions for this patient
b. Includes ‘Risk for Self Harm' to the patient's care plan
c. Documents regarding the patient's safety every 15 minutes
d. Reviews the patient's chart for references to past incidences of hopeless
ANS: B
NANDA states that a nurse is able to change any actual diagnosis on the NANDA list to a risk diagnosis if the problem has not occurred yet. The remaining options, although not inap-propriate, do not related to NANDA.
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The nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patient's blood pressure is 90/60 mm Hg and apical pulse is 102. The nurse's first action would be to:
1. check the dressing for bleeding. 2. notify the RN. 3. document the vital signs. 4. increase the rate of infusion of IV fluids.
The nurse is preparing to administer a medication to a 6-month-old infant. The nurse will monitor closely for signs of drug toxicity based on the knowledge that, compared to adults, infants have
a. an increased percentage of total body fat. b. immature hepatic and renal function. c. more protein receptor sites. d. more rapid gastrointestinal transit time.
A student nurse asks a nurse which client situations are considered involuntary responses to autonomic nervous system control? What is the nurse's best response(s)?Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
A. Sweating when hot B. Stepping over a chair to prevent falling C. Complaining of nausea D. Salivating at the smell of food E. Breathing deeper when running
________ is a conversion factor for converting grains to milligrams.
A. 
B. 
C. 
D. 