A patient says, "I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study." Which term should the nurse use to document this complaint?
a. Depersonalization
b. Hypochondriasis
c. Dissociation
d. Malingering
ANS: A
Depersonalization involves a persistent or recurrent experience of feeling detached from and outside one's mental processes or body. Although reality testing is intact, the detached experience causes significant impairment in social or occupational functioning and distress to the individual. Malingering involves a conscious process of intentionally producing symptoms for an obvious benefit; dissociation is an unconscious defense mechanism to protect the individual against overwhelming anxiety. Hypochondriasis involves the interpretation of body sensations as symptomatic of a serious illness.
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What is the pulse pressure of a patient whose blood pressure is 132/82 mm Hg?
A) 100 B) 1.6 C) 214 D) 50
A client newly diagnosed with diabetes has also been diagnosed with depression. The nurse knows to be alert for:
1. Increased low blood glucose results 2. Increased high blood glucose results 3. Failure to follow treatment plans 4. Anger and potential of violence against significant others.
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a. Biot's respirations. b. Cheyne-Stokes respirations. c. Kussmaul respirations. d. Hypoventilation