A client diagnosed with schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?
A. Magical thinking; administer an antipsychotic medication
B. Persecutory delusions; orient the client to reality
C. Command hallucinations; warn the psychiatrist
D. Altered thought processes; call an emergency treatment team meeting
C
The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.
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A patient, age 68, has a long history of COPD and is admitted to the hospital with cor pulmonale. He says his doctor said his heart was failing and asks whether he is having a heart attack. Which explanation by the nurse is most correct?
a. "You aren't having a heart attack, but your heart has been damaged by changes in your lungs caused by your respiratory disease." b. "It could be a heart attack, and when the heart is damaged it causes respiratory damage, too." c. "It isn't a heart attack, but your heart has gradually weakened over the years, causing respiratory disease." d. "It is probably a heart attack, since cor pulmonale means that the heart isn't getting enough blood and becomes too weak to pump effectively."
The nurse should assist the client with chronic cholecystitis to plan meals that are:
1. high in calories. 2. cold, small in quantity, and low in fats. 3. cold, large in quantity, and infrequent. 4. hot and high in carbohydrates.
A community health nurse provides an annual flu prevention workshop at a local senior center
The activities include a lecture on preventing infections, which includes hand washing and limit-ing exposure to individuals who are ill, as well as an influenza immunization clinic. The nurse is basing her activities on what theory of aging? a. Wear and tear b. Oxidative stress c. Autoimmune d. Free radical
A patient on long-term corticosteroid therapy is diagnosed with osteoporosis. The corticosteroids are discontinued, but the patient remains concerned about her osteoporosis and long-term prognosis
Which of the following statements is the nurse's best response to the patient's concerns regarding the corticosteroid therapy's effect on her osteoporosis? A) "Now that the corticosteroids have been stopped, you will regain the lost bone mass in about 2 months." B) "Discontinuing the corticosteroids will halt the progression of osteoporosis, but restoration of the lost bone mass usually does not occur." C) "Studies indicate that after stopping steroid therapy you will continue to lose bone mass for approximately 12 to 18 months, but the physician will prescribe a medication to strengthen your bones during this period of time." D) "With the intake of adequate calcium and vitamin D, you will see a rapid restoration of lost bone mass over the next 3 to 6 months."