A nursing diagnosis relevant for both the client with depression and the client with acute mania is
a. deficient diversional activity.
b. defensive coping.
c. sleep pattern disturbance.
d. excess fluid volume.
C
Physical needs of clients with mood disorders include sleep pattern disturbances. Assessment data
should be routinely gathered about this possible problem. Option A is more relevant for clients with
depression. Option B is more relevant for clients with mania. Option D is less relevant for clients
with mood disorders than is fluid volume deficit.
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MC The priority method for site preparation for central catheters is
A. An alcohol prep pad; cleanse from inner aspects outward to the periphery. B. A 2% chlorhexidine skin prep applicator. C. A 10% povidone-iodine prep pad. D. Tincture of iodine soaked 2" 3 2" gauze pads.
The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy
The patient states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication? A) "You will need the pain medication for at least 1 week to help in your recovery. What do you mean you feel you won't get better faster?" B) "Pain medication will help to decrease your pain and increase your ability to breath. Dependency is a risk with pain medication, but you are young and won't have any problems." C) "Pain medication can be given by mouth to prevent the risk of dependency that you are worried about. The pain medication has not been shown to affect your risk of a slowed recovery." D) "You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time."
The 7-year-old boy's hands were badly burnt; it was suspected that his mother had forced his hands into boiling hot water after she caught him masturbating. The staff did not want the mother to be allowed near the boy
Which of the following statements would be made by the nurse to encourage the staff to interact more objectively with the mother? a. "If we won't let the mom near, who does the child have for support at this painful time?" b. "Most abusers were themselves abused as children and need help to learn how to be a more effective parent." c. "The child may feel responsible; we have to let the mother fix their relationship." d. "We need to encourage the mother to continue parenting him or the boy will become a ward of the state."
What is the most important factor contributing to limitations in self-care and independent living among the elderly?
A) Lack of family support B) Low financial assets C) Acute illness and injury D) Chronic illness