A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation stress syndrome. Which action should the nurse include in the plan of care?
a. Remind the patient that making changes is usually stressful.
b. Discuss the reason for the move to the facility with the patient.
c. Restrict family visits until the patient is accustomed to the facility.
d. Have staff members write notes welcoming the patient to the facility.
ANS: D
Having staff members write notes will make the patient feel more welcome and comfortable at the long-term care facility. Discussing the reason for the move and reminding the patient that change is usually stressful will not decrease the patient's stress about the move. Family member visits will decrease the patient's sense of stress about the relocation.
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The nurse is caring for a patient with a diagnosis of catatonic schizophrenia. The behavior consistent with this diagnosis is the patient:
a. talks excitedly about going home. b. suspiciously watches the staff. c. stands on one foot for 15 minutes. d. states he has a cat under his bed that talks to him.
The nurse documents episodes of echolalia when, after the nurse has asked a catatonic patient, "Where is your hat?" the patient:
a. excitedly says, "Hat, cat, rat, fat, scat, splat!" b. begins to cry and says, "I had a hat when my mother drove her yellow car." c. repeatedly says, "Your hat, your hat, your hat." d. places his hands on his head, saying, "Where is your hat?"
While caring for a patient with a pulmonary arterial catheter, the nurse notes that the number of centimeters of exposed catheter has decreased. What nursing action is indicated?
1. Report this finding immediately; the patient may need another chest X-ray to check for placement. 2. Flush the ports. 3. Obtain a pulmonary artery occlusion pressure. 4. Zero balance the system.
The female client belongs to a religious community that requires women to dress conservatively in clothing that covers the arms and the knees. This client expresses concern that her body will be exposed during a scheduled cardiac catheterization
How should the nurse respond to this concern? 1. Tell the client that medical personnel have seen so many people's bodies that they don't even notice any longer. 2. Make a note in the client's chart that she is particularly modest. 3. Explain to the client that in order to perform the study, her body must be exposed. 4. Ask the cath lab charge nurse to come to the client's room to talk with her about the concerns.