A patient is depressed, mute, and motionless. According to family members, the patient has refused to bathe or eat for a week. The patient's global assessment of functioning score is:
a. 100
b. 50
c. 25
d. 10
D
The patient is unable to maintain personal hygiene, oral intake, or verbal communication. The patient is a danger to self because of not eating. The distracters represent higher levels of functioning.
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What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?
a. Guide the child to the floor if the child is standing, and then go for help. b. Move objects out of the child's immediate area. c. Stick a padded tongue blade between the child's teeth. d. Manually restrain the child.
An ICU nurse manager has been struggling to correct client care issues on the unit and has asked the unit director for assistance. The director says, "Training and discipline on your unit is your responsibility. I have other things to do
" Now, the manager is faced with disciplining a nurse regarding another client care issue. What is the most significant reason this manager is hesitant to administer this discipline? 1. The nurse may quit. 2. The nursing staff is a cohesive group and might retaliate. 3. The manager is not comfortable with confrontation. 4. The manager does not feel supported by the director.
Which of the following statements by patients should prompt the nurse to assess for potential failure of the adrenal cortex?
A) "I'm always exhausted these days, and I never really feel like eating." B) "Lately, I find that I'm more irritable and impatient than normal." C) "The last little while I get numbness and tingling in my lips and fingers a lot." D) "My thirst is almost insatiable these days, and my mouth always feels dry."
A postpartum client has inflamed hemorrhoids. Which of the following nursing interventions would be appropriate?
1. Encourage Sitz baths. 2. Position the client in the supine position. 3. Avoid stool softeners. 4. Decrease fluid intake.