A patient reports hearing noises when alone in a quiet room. What action should the nurse take?
1. make sure the patient is referred to a psychiatrist
2. document that the patient has a mental illness
3. ask if the patient experiences any visual disturbances
4. explain to the patient that this is not unusual
Correct Answer: 3
Information about perception difficulties such as visual and/or auditory disturbances is an important part of the health history of the nervous system. The nervous system controls cognition and sensory function, which includes vision and auditory changes. Making a referral to a psychiatrist would not be the appropriate next step, and it is not within the scope of nursing practice to document mental illness. Hearing and vision changes are not usual assessment findings and should be investigated.
You might also like to view...
The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:
A) Daily weight B) Serum sodium levels C) Measured intake and output D) Blood pressure
A patient with pulmonary tuberculosis (TB) is preparing for discharge from the hospital. The nurse is providing teaching on the medication regimen that the patient will follow at home
What medications are considered first-line medications in TB therapy? A) INH, rifampin, pyrazinamide, and ethambutol B) Capreomycin, INH, ethionamide, and cycloserine C) Rifampin, pyrazinamide, cycloserine, and ethionamide D) Capreomycin, ethambutol, INH, and pyrazinamide
The nurse is teaching the parents of a toddler-age child about injury prevention. Which statement by the parent indicates the need for further education?
1. "I will turn the handles of the pots outward while I am cooking dinner." 2. "We will make sure that our child always wears a life vest when we are out in the boat." 3. "I will keep all our medications out of reach and ensure child-resistant containers." 4. "We will provide safe climbing toys for our child."
Facility staff are not responsible if a confused patient engages in a sexual act with an alert patient.
Answer the following statement true (T) or false (F)