The nurse is preparing to perform the cover and uncover test on a client. Which explanation will the nurse provide the client prior to performing the exam?
A. This will test the muscles that control your eye movement.
B. This will test the balance mechanism that keeps your eyes parallel.
C. This will test the ability of your pupil size to change.
D. This will test the ability of your eyes to focus on distant objects.
Answer: B
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A client with chronic paranoid schizophrenia is scheduled to be discharged from the inpatient psychiatric unit in two days
The nurse is working with the client's family to develop a plan for managing psychotic symptoms and emergency behaviors after discharge. Which of the following nursing diagnoses is most appropriate? 1. Noncompliance: Medication Regimen related to paranoid ideation 2. Self-Care Deficit: Bathing/Hygiene related to irrational thought processes 3. Knowledge Deficit: Symptom Management related to inadequate understanding of disease processes 4. Risk for Violence Directed Toward Others related to delusional and persecutory thought process
Which client would the nurse assess as being at greatest risk for becoming noncompliant with his or
her treatment recommendations? a. G, who has diabetic neuropathy and depression b. H, who has had a mild stroke and arteriosclerosis c. I, who has chronic obstructive pulmonary disease and altered role performance d. J, who has unstable angina and type 2 diabetes
Identify the initial intervention by the nurse that is most effective in treating a 23-year-old woman who is diagnosed with a dependent personality disorder
a. Encouraging the client to make more de-cisions, starting with simple ones like what to select from a menu b. Teaching the client about the nature of the disorder and what the usual treatments are for it c. Placing the client in a group therapy ses-sion with other clients who have depen-dent personality disorder d. Working with the client to identify and express feelings of anger
A pt is receiving a cholinesterase (ChE) inhibitor drug for the treatment of MG. what is a nursing implication for the safe administration of this med?
a. monitor for orthostatic hypotension b. take the pt's apical pulse prior to administration c. feed meals 45-60 min after administration d. drink at least 8 glasses of water each day