A client admitted last night with a compound fracture of the femur, sustained in a fall while
intoxicated, points to the traction apparatus and screams that she sees a hangman's noose.
The
assessment that can be made is that the client is experiencing
a. an illusion.
b. a delusion.
c. hallucinations.
d. hypnagogic phenomenon.
A
The client is misinterpreting a sensory perception when she sees a noose instead of traction. Illusions
are common in early withdrawal from alcohol. Option B: A delusion is a fixed, false belief. Option
C: Hallucinations are sensory perceptions occurring in the absence of a stimulus. Option D:
Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.
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The school nurse is giving a presentation to the PTO about spinal cord injuries. What would the nurse tell the attendees of the presentation are prominent risk factors for SCI? (Mark all that apply.)
A) Young age B) Driver C) African American D) Male gender E) Alcohol or drug use
The nurse teaches the patient how to administer eye ointment. Instruction by the nurse has been correct if the patient demonstrates which technique?
a. Moistens the finger with sterile saline b. Places a thin ribbon of ointment along the conjunctiva c. Rubs the medication briskly after applica-tion d. Looks downward before application of the ointment
A nurse is preparing to establish a therapeutic relationship with a client. Which is the first essential nursing intervention that the nurse should complete?
A) Clarifying one's own attitudes, values, and beliefs B) Obtaining thorough assessment data C) Determining the client's length of stay D) Establishing personal goals for the interaction
What is an important consideration for the future of nursing theory development?
A) Development of interdisciplinary theory B) Integration of theory and research into practice C) Theory applicable to health care D) Theory which is specific to nursing