The client with bulimia is experiencing anxiety. What action should the nurse take to assist the client to avoid binge eating and purging in response to the anxiety?
1. Assume a matter-of-fact attitude and positive expectations of the client.
2. Project a calm reassuring attitude and provide a quiet non-stimulating environment.
3. Contract for safety since the client is likely to engage in self-injurious behavior.
4. Maintain total control of the environment and project an attitude of authority.
2
Rationale: The goal is to assist the client to recognize events creating anxiety and to cope with them. A calm environment will decrease anxiety-producing situations. There is no indication the client is in imminent danger of self-harm. Projecting an attitude of authority or setting expectations may increase the client's anxiety.
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Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
A) Keep the head of the bed (HOB) flat at all times. B) Teach the patient to perform the Valsalva maneuver. C) Administer benzodiazepines on a PRN basis. D) Perform endotracheal suctioning every hour.
A client recovering from a penetrating injury to the eye tells the nurse that he can see some shadows and movement with the eye. The nurse realizes this information would be considered as:
1. Deterioration in vision. 2. Improvement in vision. 3. An indication of poor nutrition. 4. The need for artificial tears.
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1. Ineffective Health Maintenance 2. Impaired Skin Integrity 3. Ineffective Coping 4. Ineffective Protection
A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck traction and screams, "Somebody tied me up with ropes." The patient is experiencing:
a. illusion b. delusion c. hallucinations d. hypnagogic phenomenon