The nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client's home, the ordinarily immaculate house is in chaos and the client is disheveled, with the odor of alcohol on his breath. Which statement by the nurse would be therapeutic?
A. "I can see that this isn't a good time to visit."
B. "You seem to be having a very difficult time."
C. "Do you think your wife would want you to behave like this?"
D. "What are you doing? How much are you drinking, and how long has this been going on?"
Answer: B. "You seem to be having a very difficult time."
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After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching?
a. "I'll be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by my dentist in 2 weeks." c. "I must avoid eating foods high in vitamin K, like spinach." d. "I must use an electric razor instead of a straight razor to shave."
A nurse has completed morning care for a client in strict isolation, including taking the client's vital signs. Which of these approaches should the nurse use in recording vital signs and other assessment data?
a. Repeat data to oneself and record them on the client's chart after leaving the room. b. Open the door and request that another nurse write down the data. c. Record data on a piece of paper without making contact with articles in the client's room. d. Keep a running record of data on a tablet in the client's room.
A grievance brought by a staff nurse against the unit manager requires mediation
At the first mediation session, the staff nurse repeatedly calls the unit manager's actions unfair, and the unit manager continues to reiterate the reasons for her actions. What would be the best course of ac-tion at this time? a. Send the two disputants away to reach their own resolution. b. Involve another staff nurse in the discus-sion so as to clarify issues. c. Ask each party to examine her own mo-tives and issues in the conflict. d. Continue to listen as the parties repeat their thoughts and feelings about the con-flict.
The nurse is caring for a critically ill patient with a severe midbrain injury involving the hypothalamus. Which vital sign is most critical for the nurse to monitor closely for this patient?
a. Temperature b. Pulse c. Respiration d. Blood pressure