The nurse is working with a client within the assessment phase of the nursing process. Which activity will the nurse NOT do during this phase?
a. Data collection c. Data documentation
b. Data verification d. Data evaluation
ANS: D
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A nurse observes an acutely psychotic client scratching at his arms with his fingernails until his arms bleed. When asked what is happening, the client states he is trying to let the evil spirits out of his body
He is easily redirected by the nurse, but resumes scratching when the nurse leaves his side. The nurse orders 1:1 supervision of the client to keep him from harming himself. Which principle of bioethics was applied in this situation? 1. Justice 2. Fidelity 3. Beneficence 4. Veracity
When assessing the client's recent memory, the caregiver concentrates on those events that occurred within ____ weeks
1. 6 2. 2 3. 4 4. 3
The nurse is concerned about being sued for negligence when providing care. Which nursing actions may be grounds for negligence? Select all that apply
A) Client fell getting out of bed because the call light was not used. B) Client name band was checked prior to providing all medications. C) Client's morning medications were administered in the early afternoon. D) Client states not understanding activity restrictions and wound eviscerated. E) Client documentation did not include appearance of infiltrated IV site.
An 82-year-old male is admitted for observation after a fall. What is this patient at increased risk for?
A) Hematoma B) Skull fracture C) Embolus D) Stroke