A patient receiving interferon experiences confusion, somnolence, and aphasia. The nurse will perform which action?
a. Discontinue the medication immediately.
b. Inform the family that these symptoms may persist for years.
c. Reassure the patient that these side effects are reversible.
d. Request an order for lorazepam.
ANS: C
Neurologic side effects, such as confusion, somnolence, and aphasia, are reversible after the drug is stopped. It is not necessary to stop the medication unless the symptoms progress and become severe. Lorazepam is not indicated.
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What is an example of a physiologic measurement?
a. Definition of a type A behavior pattern b. Description of self-care behavior abilities in patients with dementia c. Ranges of values on two consecutive arterial blood gas analyses d. Adjusted scores on the State-Trait Anxiety Scale
Which statement made by an adolescent patient represents an indirect expression of low self-esteem?
a. "It seems as if I have been a loser almost since the day I was born.". b. "Drinking beer almost always helps me to forget about my problems.". c. "I don't have many friends, and I tend to stay away from the ones I do have.". d. "If I had only gotten that job, then I could certainly experience happiness in life.".
A nurse is reviewing a drawing that a client completed as a self-portrait. The nurse observes that the drawing lacks arms and feet. The nurse interprets this as indicating which of the following? Select all that apply
A) Low self-esteem B) Powerlessness C) Insecurity D) Inadequacy
The mother of a child with autism spectrum disorder tells the nurse that her child has few playmates. She states, "He has real trouble interacting with other children and when there is a change in his routine, he throws a tantrum."
Based on this information, the nurse identifies which nursing diagnosis as the priority? A) Self-Care Deficits related to repeated tantrums B) Risk for Injury related to autism spectrum disorder C) Compromised Family Coping related to having a child with autism spectrum disorder D) Social Isolation related to poor social skills