A patient diagnosed with delirium stares at the corner of the room, wrings hands, and says, "I'm scared those snakes will bite me." The nurse should document
a. agnosia.
b. disorientation.
c. confabulation.
d. visual hallucinations.
D
Seeing objects that are not visible to another person can be documented as having visual hallucinations, rather than any of the other choices.
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What does maintaining eye contact for 2 to 6 seconds during communication with a patient do?
a. Keeps the nurse's attention on the conversation b. Counteracts shyness in the patient c. Indicates continuous focused attention d. Assesses if the patient is involved in the conversation
The nurse is assessing a client's chronic pain. The client indicates the pain is in the upper right quadrant of the abdomen, rates the pain as a 9 on a 1-10 scale, and describes the pain as sharp and continuous
What else would the nurse assess regarding this client's pain? 1. Onset, duration, and recurrence 2. Location 3. Intensity 4. Quality
The nurse on a psychiatric unit is caring for a client with severe depression. The client states, "I just cannot go on. It is hopeless for me and there is no end in sight. My family would be better off without me burdening them."
The nurse recognizes that this client is most at risk for: a. Ineffective coping b. Denial c. Impaired recovery d. Suicide
A patient who will require long-term mechanical ventilation has had a tracheostomy for 2 weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment would support the nurse's concern?
1. Secretions are present at the stoma opening. 2. Granulation tissue is noted at the stoma site. 3. The patient has developed a dry cough. 4. The skin at the stoma opening is flaky.