A client with paranoid schizophrenia is experiencing visual hallucinations of people jumping out of nowhere. The client keeps striking the wall
Repeated attempts by the nurse to orient the client to reality and reassure the client of safety have failed. What would be the nurse's next de-escalation approach? 1. Offer the client a PRN medication
2. Apply soft limb restraints on client's wrists
3. Have several staff demobilize the client so that forcible injection can be administered
4. Call security to assist in placing the client in seclusion
1
Rationale: Offering the client a PRN medication would be the next step as attempts at verbal de-escalation have failed. Restraints are the most restrictive intervention and not warranted at this point. Seclusion will not prevent the client from self-harm inflicted by beating the walls. Forcing medication is a chemical restraint and not warranted until voluntary medication has been refused.
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A 79-year-old woman suffering from dementia of the Alzheimer's type resides in an independent living long-term care facility. During a recent nursing visit, the client was quite upset about the loss of her frying pan
While complaining about its loss, she was holding the pan in her hand. The nurse pointed out to the client that she had the pan she was looking for. The client looked at the pan and stated, "No, this is not it." The nurse knows the client is exhibiting: 1. Aphasia. 2. Agnosia. 3. Apraxia. 4. Nystagmus.
A child who weighs 18 kg and is 88 cm tall has a BSA of ______________
a. 0.71 m2 b. 0.51 m2 c. 0.66 m2 d. 0.44 m2
What medication would the nurse question if ordered for a pediatric patient?
A) Amikacin B) Cefazolin C) Streptomycin D) Levofloxacin
A client with osteoarthritis of the knees tells the nurse that no one else in the family has this disorder. What assessment finding might have increased this client's risk for developing this disorder?
A) Body mass index 36.5 B) History of esophageal reflux disease C) Client plays tennis 3 times each week D) Blood pressure 136/78 mmHg