A nurse notices a client clenching fists periodically and pacing the hallway. Which of the following nursing interventions would best assist the client at this time? Select all that apply
A. Acknowledge the client's behavior.
B. Initiate forced medication protocol.C. Assist the client to a quiet area.
D. Initiate confinement measures.
E. Speak with a soft and calming voice.
A, C, E
The nurse should remain calm when dealing with an angry client. It is important to acknowledge the client's behavior and assist the client to a less stimulating environment.
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The nurse is teaching a patient with glaucoma how to instill eyedrops. The nurse would instruct the patient to take which of the following actions?
a. Look straight ahead while pulling down the lower eyelid. b. Look up while pulling lower lid outward. c. Squeeze the eyelids shut for 2 minutes after instillation. d. If the eye waters, wipe from the outer canthus to the inner canthus.
The nurse is teaching parents to plan nutritional meals for their son who is overweight. Which of the following guidelines might the nurse include in the teaching plan?
A) School-age children with an average body weight of 20 to 35 kg need approximately 90 calories per kilogram daily. B) The average water requirement for a school-age child per 24 hours ranges from 2,000 to 2,500 mL per day. C) The school-age child needs 28 g of protein and 800 mg of calcium for maintenance of growth and good nutrition. D) In the school-age child, calories needed to sustain weight increase, while the appetite decreases.
After undergoing two electroconvulsive therapy (ECT) treatments, a client decides to discontinue the therapy. The client then changes her mind and continues with ECT treatment
Later that week, the client refuses to get dressed, eat meals in the dining area, or go to group therapy. When planning care, which nursing diagnosis should be the lowest priority at this time? A) Anxiety related to confusion and memory loss B) Risk for injury related to post-ECT confusion and memory loss C) Disturbed thought process related to confusion and memory loss D) Activity intolerance related to post-ECT confusion and memory loss
The nurse caring for a patient with AIDS who receives agenerase is preparing the patient for discharge. What dietary counseling will the nurse provide based upon the patient's medication regimen?
A) Avoid high-fat meals while taking this medication B) Limit fluid intake to 2 L per day C) Limit sodium intake to 2 g per day D) Avoid meals high in protein while taking this medication