Before administering a prescribed antipsychotic drug to a client, the nurse observes the client for any behavior patterns that appear to be deviations from normal. Which of the following would the nurse identify as a deviation? Select all that apply
A) Poor eye contact
B) Monotone speech pattern
C) Inappropriate laughter
D) Failure to answer questions completely
E) Inappropriate crying
Ans: A, B, C, D, E
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Examples of deviation from normal include poor eye contact, failure to answer questions completely, inappropriate answers to questions, a monotone speech pattern, and inappropriate laughter, sadness, or crying.
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A community health nurse arrives at a family's home. Which of the following behaviors by the nurse would be nontherapeutic?
A) Maintaining eye contact with the family members B) Continuously paging through paperwork for information C) Sitting on the furniture near the family members D) Placing car keys in the nurse's carry-all bag
The nurse suspects that a client should be evaluated for diabetes mellitus. What risk factors did the nurse assess to make this clinical determination? (Select all that apply.)
1. Has a body mass index of 40 2. Triglyceride level 325 mg/dL 3. Mother has type 2 diabetes mellitus 4. Serum potassium level is 4.2 mEq/L 5. Has a blood pressure of 156/88 mm Hg
The nurse adds a nursing order to the care plan related to a patient with a nursing diagnosis of Nutrition: less than body requirement related to nausea and vomiting. The statement that is a nursing order is:
a. medicate with an antiemetic before each meal. b. offer crackers and iced drink before each meal. c. change diet to clear liquids. d. give nothing by mouth until nausea sub-sides.
Type 2 diabetes is a complex disorder involving:
1. Absence of insulin production by the beta cells 2. A suboptimal response of insulin-sensitive tissues in the liver 3. Increased levels of glucagon-like peptide in the postprandial period 4. Too much fat uptake in the intestine