A newly admitted client diagnosed with paranoid schizophrenia believes co-workers are "out to get"
him and has stated he thinks two doctors on the unit are plotting to kill him. How does the client
perceive the environment?
a. Supportive
b. Dangerous
c. Disorganized
d. Bizarre
B
The client sees his world as hostile and dangerous. This assessment is important because the nurse
can be more effective by using empathy to respond to the client. Data are not present to support any
of the other options.
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A nurse is assessing a client who presents with a scaly rash over the palms and soles of the feet and the feeling of muscle aches and malaise. The nurse suspects syphilis. Which action by the nurse is appropriate?
a. Reassure the client that this stage is not infectious unless she is pregnant. b. Assess the client for hearing loss and generalized weakness. c. Don gloves and further assess the client's lesions. d. Take a history regarding any cardiovascular symptoms.
An older man who had radical surgery for oral cancer is refusing to see visitors and is losing weight, despite aggressive nutrition therapy. The nurse assesses this man for ineffective coping, related to dysfunctional grieving
Which of the following patient outcomes of nursing care is the most important to implement in response to his mental health status? a. Is able to discuss how his coping mechan-isms are overwhelmed. b. Performs daily self-feedings through a gastrostomy tube. c. Effectively uses nonverbal forms of communication. d. Exhibits self-confidence in regaining a sense of control.
A recently graduated nurse wants to register with a nurse's registry. What should the nurse keep in mind before registering with the agency?
A) It recruits nurses only for part-time jobs in healthcare facilities. B) It does not provide insurance coverage to nurses. C) It conducts informational interviews for nurses. D) It allows nurses to choose their own schedules.
During assessment of a client, the chest tube becomes dislodged. The nurse should first:
A. Call the physician B. Check for a mediastinal shift C. Attempt to gently reinsert the tube D. Apply pressure over the insertion site