The nurse has completed her assessment of a client admitted with delirium tremens. Which of the following is the nursing priority for a client in alcohol withdrawal?
1. Ineffective Coping
2. Disturbed Thought Processes
3. Risk for Suicide or Injury
4. Disturbed Sensory Perception
3. Risk for Suicide or Injury
Rationale:
A client in alcohol withdrawal is at risk for injury from delirium tremens. Death from delirium tremens can occur from volume depletion, electrolyte imbalance, cardiac arrhythmia, or suicide. Ineffective coping is a potential diagnosis used in substance abuse. Disturbed thought processes and disturbed sensory perceptions are diagnoses used for delusions, hallucinations, and illusions that may occur during delirium tremens.
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The nurse works with cancer patients and their families to deal with difficult issues. Which of the following reasons supports why a diagnosis of malignant melanoma may be extremely difficult for patients to accept?
A) It cannot be detected early enough to improve the prognosis. B) It is a high risk in fair-skinned individuals, and incidence increases with age. C) It has been rising in the United States, probably due to sun exposure. D) It causes a small percentage of total deaths from cancer but is metastatic and fatal.
A nurse transcribes a discharge order for the patient with left-sided weakness after having a stroke indicating to teach the patient to perform range-of-motion exercises on affected extremi-ties
The patient asks why she needs to do range-of-motion exercises. What is the nurse's best response? a. "Because the physician has ordered it." b. "You will regain full use of your arm and leg if you will do the exercises correctly." c. "They prevent the muscles and tendons from shortening and becoming unmova-ble." d. "It will give you something to do because you can't work anymore."
To protect a patient's ____________________ when faxing medical records, a nurse should telephone the intended recipient to inform him or her of the impending fax to ensure that the intended recipient is present
Fill in the blank with correct word.
The heart muscle relaxes during:
a. Bradycardia b. Tachycardia c. Systole d. Diastole