The nurse is developing a plan of care for a 5-year-old child with a severe hearing impairment focusing on psychosocial interventions based on assessment findings. Which behavior would the nurse have most likely assessed?
A) Immature emotional behavior
B) Self-stimulatory actions
C) Inattention and vacant stare
D) Head tilt or forward thrust
A
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The nurse is caring for a 15-year-old client who is dying. The client tells the nurse, "I know I am not going home again. I think it is harder for my parents than me. Will you talk to them for me?" Which of the following is the best response by the nurse?
a. "It is true that you will be dying soon, but you must be honest with your parents." b. "That's not true, but I will talk to your parents." c. "You are having a bad day, so I will be back later to see if you need anything else." d. "Yes, I will talk to your parents, but you need to talk to them also. I will help you with that."
The client receives raloxifene (Evista). Which other medication would the nurse hold and validate with the physician?
1. Lisinopril (Prinivil) 2. Paroxetine (Paxil) 3. Atorvastatin (Lipitor) 4. Diphenhydramine (Benadryl)
Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects "health" in an Asian with this belief?
a. A person is able to work and produce. b. A person is happy, stable, and feels good. c. All aspects of the person are in perfect balance. d. A person is able to care for others and function socially.
A nurse reviews vital signs for a patient admitted last night with an injury sustained while intoxicated
The medical record shows these blood pressure and pulse readings: Admission, 2 AM - 118/78 mm Hg and 72 beats/min 4 AM - 126/80 mm Hg and 76 beats/min 6 AM - 128/82 mm Hg and 72 beats/min 8 AM - 132/88 mm Hg and 80 beats/min 10 AM - 148/94 mm Hg and 96 beats/min What is the nurse's priority action? a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.