The nurse is admitting an older adult female who uses two canes for ambulation. The patient is attended by her daughter, who quietly reorients her mother several times during the assessment process. The daughter reports that her mother was a smoker for many years, but has not smoked for the last 5 years. The patient wears incontinence underwear and has problems with constipation. The nurse would
evaluate which of these findings as key risk factors from the Hendrich II Fall Risk Model?
1. The patient is female.
2. The patient has a history of using tobacco.
3. The patient wears incontinence underwear.
4. The patient requires frequent reorientation.
5. The patient uses a cane.
3, 4, 5
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Which of the following is a nonverbal behavior that enhances communication?
1) Keeping a neutral expression on the face 2) Maintaining a distance of 6 to 12 inches 3) Sitting down to speak with the patient 4) Asking mostly open-ended questions
A nurse reads the local community newspaper to gather data about the community. Which method of data collection is being used?
a. Informant interview b. Focus group c. Participant observation d. Windshield survey
A client with manic behavior was admitted to the unit this morning. The client is pacing the floor and has pressured speech showing flight of ideas
This client has a delusion that she has been canonized as a saint and is openly angry at all the "sinners" on the ward. The nurse assesses this client as high risk for assaulting behavior. Which of the following stages of mania represents this client's current state? a. stage I b. stage II c. stage III d. stage IV
The community health nurse documents in the chart that the family is blended. Using your knowledge of blended families, what are reasons for this type of family becoming more widespread?
1. Increased divorced married people 2. Increased widowed single people 3. Increased gay and lesbian relationships A) 1, 2 B) 2, 3 C) 1, 3 D) 1, 2, 3