Max says, "Nurse, see that man on the television? He is the reason why I am sick. He told them to make me this way." The nurse documents this as an episode of a(n):
A.
Hallucination.
B.
Delusion.
C.
Illusion.
D.
Autistic thought.
ANS: B
A delusion is a fixed, false belief. Hallucinations refer to altered sensory perceptions and illusions are misinterpretations of real stimuli. Autistic thoughts would not be as organized as this delusion.
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A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary care provider. d. Repeat blood pressure measurement in 15 minutes.
The nurse comes upon the scene of a multiple motor vehicle crash and decides to stop and help because there are no emergency personnel present. The first priority for the nurse is to:
1. Ensure that victims are removed from their cars. 2. Quickly check all victims and perform CPR on the most injured. 3. Assess the scene for safety to prevent more harm. 4. Begin treating clients trapped in their cars.
A large healthcare organization is planning to implement a clinical information system. What should be considered when selecting this system?
A) Training on the system should be limited. B) Nursing staff documentation needs are the priority. C) The organization needs to meet multiple competing demands. D) Laboratory data and pharmacy integration is considered nonessential.
The nurse is concerned that a patient receiving emergency care for maxillofacial injuries from a motor vehicle crash sustained laryngeal trauma because of which assessment findings? Note: Credit will be given only if all correct choices and no
incorrect choices are selected. Select all that apply. 1. Hoarse speech 2. Pain when swallowing 3. Coughing blood 4. Epistaxis 5. Periorbital edema