The nurse is working with a group of clients on a unit with mental retardation. Which of the following is the recommendation for environmental safety when clients have poor cognitive function?
1. Use measures to decrease agitation
2. Schedule ADLs at a regular time daily
3. Turn the temperature down on the hot water heater
4. Provide aids to assist with orientation
3. Turn the temperature down on the hot water heater
Rationale:
Turning the temperature down on the hot water heater will help to prevent accidental burns when bathing or washing dishes. Using therapeutic measures to decrease agitation is recommended for clients with high risk for other-directed violence. While a routine daily schedule and orientation aids will structure the client's environment to promote optimal orientation, they will not necessarily improve environmental safety.
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The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should Answer:
a. "Pancreatitis is extremely rare and no one knows why it causes pain." b. "Pancreatitis is caused by diabetes; you should be checked." c. "Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain." d. "The pain is localized to the pancreas. Fortunately, it will not affect anything else."
A patient with severe, deep partial-thickness burns experiences procedural, background, and breakthrough pain. What is the nurse's most important plan for controlling this patient's pain?
1. Administer pain medications prior to all procedures. 2. Maintain intravenous access for administration of pain medications. 3. Designate one pain assessment technique for use by all providers. 4. Expect that it will be necessary to exceed normally administered levels of analgesics.
The nurse is caring for a patient diagnosed with hypocalcemia. What additional assessments should the nurse include when caring for this patient?
1. other electrolyte disturbances 2. hypertension 3. visual disturbances 4. drug toxicity
The nurse caring for a client with renal failure will question the use of a usual dose of which medication?
1. Digoxin (Lanoxin) 2. Cholestyramine (Questran) 3. Fluvastatin (Lescol) 4. Benzylpenicillin (penicillin G)