A nurse collects a semen sample as part of a rape kit. Which event represents a break in the chain of evidence?
A) A sample is collected, labeled, sealed, and kept under observation.
B) A sample is locked in a special container until police arrive.
C) A sample, in need of refrigeration, is placed in the medication room refrigerator in an open container.
D) A sample is labeled, sealed, and immediately given to police.
C
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The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of hygiene self-care deficit. Which goal is most appropriate on day one?
a. Patient will ambulate independently twice a day. b. Patient will perform all of own ADLs. c. Patient will consume 75% of all meals. d. Patient will begin to perform 50% of own ADLs.
A client who is 2 days post–femoral vein cannulation begins to have difficulty with outflow of blood during dialysis. For which complication does the nurse assess?
a. Hematoma at cannula insertion site b. Infection c. Oliguria d. Skin necrosis at cannula insertion site
The client overdosed on amitriptyline (Elavil). The nurse would expect to see which of the following symptoms? Select all that apply
A) Seizures B) Increased coronary blood flow C) Arrhythmia D) Hallucinations E) Agitation
A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which of the following comments by the nurse would be therapeutic at this time?
1. "What is causing you to become agitated?" 2. "Why are you intent on upsetting the other clients?" 3. "Please stop so I don't have to put you in seclusion." 4. "You are going to be restrained if you do not change your behavior."