What is meant by impaired state of equilibrium?
A) Describes the client's condition
B) Is a common terminology
C) Is a nursing diagnosis
D) Assists in planning care
Ans: A
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When responding to a patient who has agitated, hostile behavior during a community meeting, the initial action the nurse should take is to:
a. follow the treatment plan. b. place the patient in seclusion. c. offer an antianxiety medication. d. permit the angry outburst if no harmful behavior is threatened.
What is a priority nursing action when a postsurgical patient complains of shortness of breath?
a. Raise the head of the bed to 30 degrees. b. Take vital signs. c. Perform a focused assessment. d. Inform the charge nurse.
Which intervention would be most therapeutic as a nurse cares for a victim of partner abuse?
a. Validate the truthfulness of the victim's comments. b. Avoid pressuring the victim or disparaging the abuser. c. Acknowledge the victim's inability to change the situation. d. Encourage the partner to stay with the victim during an interview.
How should the nurse describe associative play to a group of caregivers?
A) Children are playing apart from others without being part of a group B) Children are playing together in an activity without organization C) Children are playing in an organized group with each other D) Children are playing independently and are side by side