The nurse, working in a substance abuse rehabilitation facility, is talking with a resident who says, "I'm just here to avoid going to jail. I'm not addicted to alcohol. I just enjoy it, but I'm going to quit to avoid getting arrested again
" Which of Pender's Health Promotion Model assumptions is this resident demonstrating? Select all that apply.
a. Health professionals are part of the person's interpersonal environment.
b. The capacity for self-awareness includes assessing one's own competencies.
c. The person values positive growth and attempts to balance change and stability.
d. The person seeks to actively regulate his own behavior
A, C, D
The resident is aware of the nurse as someone in the environment, so this assumption is demonstrated. The patient evidently values growth because he has agreed to enter a treatment facility to improve his addiction issue. The resident is trying to regulate his behavior while in the treatment facility. The resident demonstrates lack of self-awareness by denying the addiction; this assumption is not being demonstrated.
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The school nurse reminds the faculty of a high school that it is imperative to report to a mental health professional any:
a. signs of depression. b. threats of suicide. c. signs of withdrawal. d. behavioral problems.
You test a patient for temperature sensation. Why is this test included?
a. It is part of the routine sensory assessment. b. Abnormal findings in superficial pain sensation were found. c. It is recommended for all patients over the age of 40. d. This test is more discriminating in patients with diabetes than the tests for touch and pain.
Despite less restrictive interventions, a patient's behavior escalates, requiring emergency application of restraints. Which of the following must the nurse do in this situation?
1) Obtain a physician's order before applying restraints. 2) Monitor the patient's status every 4 hours while restrained. 3) Release the restraints and check circulation every hour. 4) Continually reevaluate the patient's need for restraint.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patient's plan of care?
A) Monitoring of pulse oximetry B) Administration of a low-protein diet C) Administration of thorough oral hygiene D) Fluid restriction as ordered