A patient who is receiving a narcotic analgesic for pain sees shadows from the Venetian blinds and tells the nurse there are snakes on the wall. The nurse knows this patient is experiencing
a. a hallucination c. a disturbance in af-fect
b. an illusion d. a disturbance in judgment
B
An illusion is an inaccurate perception or misinterpretation of sensory stimuli. A hallucination is a sensory perception that occurs in the absence of external stimuli and is not based on reality. Affect is mood or feeling. Judgment is the ability to compare or evaluate alternatives to life situations and arrive at an appropriate course of action.
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A nurse is planning care for an older adult who lives with a number of chronic health problems. For which of the following nursing diagnoses would education of the patient be the nurse's highest priority?
A) Risk for impaired physical mobility related to joint pain B) Functional urinary incontinence related decreased mobility C) Activity intolerance related to contractures D) Risk for ineffective health maintenance related to nonadherence to therapeutic regimen
When fluids are filtered by the glomerular membrane of Bowman's capsule where does the filtrate go?
A) Back into the blood B) Into the nephrons C) Fills the space in Bowman's capsule D) Fills the nephron
A pt with MG has been referred to a surgeon for a procedure that may improve the pt's symptoms. Which procedure does the nurse anticipate will be recommended for this pt?
a. percutaneous stereotactic rhizotomy b. thymectomy c. resecting severed nerve ends d. partial or complete severance of a nerve
The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. This intervention:
a. Is adopted from classical British nursing traditions. b. Helps infants with motor and central nervous system impairment. c. Helps infants to interact directly with their parents and enhances their temperature regulation. d. Gets infants ready for breastfeeding.