A client who has myasthenia gravis (MG) has all of the following nursing diagnoses. Which would reflect the greatest threat to the client?
a. Risk for aspiration
b. Impaired verbal communication
c. Knowledge deficit related to disease process
d. Altered urinary elimination
A
Nursing care of clients who have MG includes monitoring respiratory status, preventing aspiration, and teaching about living with the disease (e.g., avoiding excessive activity, eating a snack before taking medications to minimize gastrointestinal irritation).
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The client with bipolar disorder has been on lamotrigine (Lamictal) for three years and has had a stable mood for one year and asks what the risks would be of just stopping all the lamotrigine at once
Which nursing response is the most important point? 1. Stopping this medication is usually not problematic. 2. Stopping this medication could trigger a panic attack. 3. Stopping this medication may trigger headaches. 4. Stopping this medication abruptly carries the risk of seizures.
The characteristic of genuineness helps in establishing a therapeutic relationship with a client. Which nurse response is the best example of a display of genuineness to a client who is going through a difficult divorce?
a. "I know exactly how you feel. My husband and I divorced 2 years ago because of his infidelity." b. "Divorcing my husband was the best thing I ever did." c. "I have friends who have gone through a divorce. It must be difficult for you." d. "I am sorry that you have to go through this difficult time."
Because of county need, a school nurse was transferred from a new suburban school to a large inner-city school in an older low-income neighborhood. Which of the following changes in role should be anticipated by the nurse? (Select all that apply.)
a. An increased absentee rate because of infectious diseases b. Cooperating with the school meal program to be sure fruits and vegetables and other healthy choices are included c. Regularly checking each child for visible signs of child abuse d. Emphasizing to parents that their child cannot attend school until immunizations are done e. Need for lead poisoning screening and education f. Screening for head lice several times a year
Which of the following is an example of an active listening behavior?
a. Taking frequent notes b. Asking for more details c. Leaning toward the patient d. Sitting comfortably with legs crossed