A nurse enters a client's room just as the client is drifting off to sleep. The client is initially startled by the nurse's presence and involuntarily "jumps," grabbing the side rails of the bed
Then, seeing that it is the nurse who is in the room, the client's brain "turns off" the stress response and the client calms. Which cerebral structure, sometimes referred to as the "emotional brain," is the source of this reaction?
A) The cerebellum
B) The limbic system
C) The cerebral cortex
D) The left temporal lobe
B
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The family of a newborn has just been told their infant has tetralogy of Fallot. The family does not seem to understand the explanation given by the physician. What statement by the nurse is best?
1. "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." 2. "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." 3. "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." 4. "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal."
After assessing a client, a nurse noted the following: "He was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate,
and he reported having trouble sleeping and having little or no appetite." The nurse also noted that the client's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnosis would be the most appropriate? A) Ineffective Role Performance B) Risk for Infection C) Risk for Suicide D) Risk for Self-Mutilation
When providing care for a patient with a suprapubic catheter who has acquired a UTI, which intervention is most important for the nurse to implement?
a. Using clean technique b. Securing the tube to the inner thigh c. Cleansing the insertion site in a direction toward the drain d. Promoting intake of 2200 mL of fluid per day
Nurses must be aware that disciplinary action by the state board of nursing can include such things as fines, suspension of nursing licensure, and:
a. mandatory reeducation in the area of the violation b. revocation of nursing license c. immediate retaking of the NCLEX d. a minimum of 1,000 hours of community service