The nurse has been assigned to care for a newly admitted client. As she conducts a mental status interview, she observes the client's state of hygiene, grooming, manner of dress, and facial expressions
The nurse is gathering data about the client's 1. affect.
2. appearance.
3. attention span.
4. emotional judgment.
2
The "general description" category includes everything that can readily be observed about a client, such as physical characteristics, dress, facial expressions, motor activity, speech, and reactions.
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A newly graduated nurse has been assigned to work with one assistive personnel staff member. When delegating skills, which guidelines should the nurse use? (Select all that apply.)
a. Assign just bed making skills and feeding tasks. b. Assess the knowledge of the assistive personnel. c. Match tasks to the assistant's skills. d. Have the nursing assistant document as-sessment findings. e. Assess skill levels of assistive personnel.
A monofilament test is used to determine a client's risk for which of the following complications of diabetes mellitus?
A) diabetic ulcer of the foot B) diabetic retinopathy C) diabetic ketoacidosis D) arterial insufficiency of the lower extremities
Which definition best describes Kussmaul breathing, seen in diabetic ketoacidosis or lactic acidosis?
1) Progressively increasing, rapid, deep respiration that peaks and then gradually decreases 2) Rapid and deep respirations 3) Irregular rate and depth that alternates with periods of apnea 4) Regular breathing pattern followed by brief periods of apnea
A nursing student has been feeling increasingly overwhelmed. In addition to attending nursing school, the client works full time at night to support his wife and two young children
He missed clinical this week because he overslept, and he also failed a test. His boss has reprimanded him for falling asleep on the job. This evening, his wife found him in the garage assembling a noose. When she questioned him, he began to cry. She immediately brought him to the emergency department. The nurse understands this type of crisis is: A) Maturational/developmental. B) Dispositional. C) Originating from anticipated life transitions. D) Resulting from traumatic stress.