The patient with Alzheimer's wakes up at 2:00 AM moaning and frightened and begs that her husband's coffin be removed from her room. The nurse should:
a. turn light on and say, "There is no coffin here, Mrs. Smith. This is the dresser."
b. leave the light off and shine a flashlight on the dresser and say, "See! No coffin!"
c. turn the light on, assist patient to the bathroom, and say, "This is your dresser."
d. leave the light off and say, "You are in your room, Mrs. Smith."
C
Turning the light on helps reorient the patient. Distraction of going to the bathroom and identi-fying the dresser assist with reorientation after a frightening illusion. The other options would lead to greater confusion.
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A 19-year-old Mexican American is about to start taking ethambutol (Myambutol). Before beginning drug therapy, it would be critical for the nurse to assess the patient's
A) alcohol use and that it is carefully documented. B) blood glucose level. C) gross hearing and establish a baseline. D) visual acuity and establish a baseline.
When teaching a patient with asthma how to use a metered dose inhaler (MDI) correctly, it is important to emphasize which of the following?
A) Rapid breathing during treatment to facilitate more medication in lungs B) Allow 5 minutes between each puff C) Hold breath as medication is released D) Position inhaler approximately 1 to 2 inches from the open mouth
The ICU unit has a client in which the family has been verbally abusive and has threatened staff. The manager notes an increase in absenteeism with the staff over the past 2 days. The manager believes this is attributed to a:
1. Staffing dilemma caused by the scheduler. 2. Change in the staffing matrix. 3. Decline in staff morale due to a hostile environment. 4. Miscommunication between management and nursing administration.
The nurse must administer eardrops to an infant. How should she proceed?
1) Pull the pinna down and back before instilling the drops. 2) Pull the pinna upward and outward before instilling the drops. 3) Instill the drops directly; no special positioning is necessary. 4) Position the patient supine with the head of the bed elevated 30°.