A client is noted to have a high level of non-goal-directed motor activity, running from chair to chair in the solarium. He is wide eyed and seems terror stricken. He repeats "They are coming! They are coming!" He neither follows staff direction nor responds to verbal efforts to calm him. The level of anxiety can be assessed as
A. mild.
B. moderate.
C. severe.
D. panic.
Answer: D. panic.
You might also like to view...
A woman you are caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective
Your best response would be that A) she needs to rest because her contractions are hypertonic. B) her physician will order oxytocin to strengthen contractions. C) hypotonic contractions of this kind will strengthen by themselves. D) walking around will make her contractions more regular.
The nurse is preparing a handout for female adolescents on the menstrual cycle. What phase of the cycle occurs if fertilization does not take place?
1. Menstrual 2. Proliferative 3. Secretory 4. Ischemic
The mother of a toddler-age client states, "My daughter seems to be at an increased risk for complications associated with respiratory infections." Which response by the nurse is accurate?
1. "You are incorrect in your assessment." 2. "The younger child's airways are smaller and more easily occluded." 3. "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children." 4. "Toddlers do not breathe as deeply as do older children."
A nurse is preparing to administer a medication from a vial. In which order will the nurse perform the steps, starting with the first step?
1. Invert the vial. 2. Fill the syringe with medication. 3. Inject air into the airspace of the vial. 4. Clean with alcohol swab and allow to dry. 5. Pull back on the plunger the amount to be drawn up. 6. Tap the side of the syringe barrel to remove air bubbles. a. 4, 1, 5, 3, 6, 2 b. 1, 4, 5, 3, 2, 6 c. 4, 5, 3, 1, 2, 6 d. 1, 4, 5, 3, 6, 2