A patient fearfully runs from chair to chair crying, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to:
a. provide for the patient's safety.
b. encourage clarification of feelings.
c. respect the patient's personal space.
d. offer an outlet for the patient's energy.
ANS: A
Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Offering an outlet for the patient's energy can occur when the current panic level subsides. Respecting the patient's personal space is a lower priority than safety. Clarification of feelings cannot take place until the level of anxiety is lowered.
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After teaching a class about the differences in the skin of infants and adults, the nurse determines that additional teaching is necessary when the class states which of the following?
A) "An infant's skin is thinner than an adult's, so substances placed on the skin are absorbed more readily." B) "The infant's epidermis is loosely connected to the dermis, increasing the risk for breakdown." C) "The infant has a lower risk for damage from ultraviolet radiation because the skin is more pigmented." D) "An infant has less subcutaneous fat, which places the infant at a higher risk for heat loss."
Which statement made by the mother of an adolescent being discharged after spinal fusion for severe scoliosis indicates the need for further teaching?
a. "I am glad we chose surgery. Now it is all over and done.". b. "I'll see you in a month; we'll be back fairly regularly.". c. "I have to pick up some more T-shirts on the way home.". d. "Those exercises the physical therapist showed us were not too hard.".
Write the Arabic numerals for XV
What will be an ideal response?
Identify an accurate statement about the nerve supply of the heart.
A. The sympathetic nerves that innervate the heart become active when the body needs to rest and conserve energy. B. The norepinephrine released by the sympathetic nerves in the heart act on the sinoatrial (SA) node to decrease heart rate. C. The autonomic nervous system regulates the rate and force of the contractions of the heart. D. The heart receives its nerve supply from only one division of the autonomic nervous system, the sympathetic division.