In the initial stages of caring for a client who is experiencing an acute manic episode, which should be the priority nursing diagnosis?
A) Risk for injury related to excessive hyperactivity
B) Insomnia related to manic hyperactivity
C) Imbalanced nutrition, less than body requirements, related to inadequate intake
D) Situational low self-esteem related to embarrassment secondary to high-risk behaviors
A
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The topic of urinary incontinence is frequently embarrassing for older adults. It is essential to include all of the following except
a. Assessment of current medications b. Previous bowel and bladder regimen c. Psychosocial issues regarding incontinence d. Ability to sit with legs dependent
A nurse teaches a female patient to follow which principle for self-catheterization?
A) Assume a supine position for self-catheterization. B) Use a clean technique at home to catheterize. C) Insert the catheter 1 to 2 inches into the urethra. D) Self-catheterize every 2 hours at home.
When told that he is scheduled to interview a client with narcissistic personality disorder, the nurse
can anticipate the assessment findings will include the following: client a. is charming, dramatic, seductive; seeks admiration. b. is preoccupied with minute details; is a perfectionist. c. describes difficulty being alone; shows indecision, submissiveness. d. is grandiose, self-important, and has a sense of entitlement.
A patient with a history of sleep apnea is experiencing difficulty maintaining an airway during conscious sedation. What should the nurse do to assist this patient?
1. Prepare to administer a reversal agent. 2. Begin artificial ventilations. 3. Measure oxygen saturation. 4. Apply prescribed oxygen via face mask.