When a client with paranoid schizophrenia tells the nurse "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be
A. "You are safe here. This is a locked unit and no one can get in."
B. "I do not believe I understand the word volmers. Tell me more about them."
C. "Why do you think someone or something is going to harm you?"
D. "It must be frightening to think something is going to harm you."
Answer: D. "It must be frightening to think something is going to harm you."
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Which nursing interventions will be implemented for the mother of a 10-month-old infant with nonorganic failure to thrive?
a. Pointing out errors that the nurse observes when the mother is caring for the infant b. Discussing negative characteristics of the infant with the mother c. Having the nurse provide as much of the infant's care as possible d. Teaching the mother about the developmental milestones to expect in the next few months
How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter?
a. At least once a day b. At least twice a day c. At bedtime d. Each shift
A nurse is trying to keep a confused resident from removing a feeding tube by following the "rule of least restriction." What should replace the wrist restraint?
a. Mittens b. Vest restraint c. Administration of a mild sedative d. Tightly tucked sheet
The nurse receives the results of laboratory testing and sees that the level of valproic acid in the client's blood is 78 mcg/mL. What is the nurse's most appropriate response?
a. The nurse must call the physician immediately; this is a toxic level of medication. b. He or she must do nothing; this is a therapeutic level of medication. c. He or she must call the physician; this is a dangerously high level of medication. d. The nurse must do nothing; this is a subnormal level of medication.