When assessing a client for depression, which of the following would the nurse most likely find?
A) Drowsiness
B) Extreme sadness
C) Severe headache
D) Dilated pupils
Ans: B
Feedback:
The nurse should monitor the client for extreme sadness because this is a symptom of depression. Drowsiness is an adverse effect of most antidepressants. Severe headache and dilated pupils are symptoms of hypertensive crisis.
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A client using a color scale to identify pain levels has selected the color purple as the level of pain experienced. The nurse should plan which intervention for the client?
1. Administration of pain medication 2. Repositioning the client 3. Distraction 4. Guided imagery
The SBAR approach to patient safety encourages:
a. Consistency in assessment and practices. b. Continuing education. c. Multidisciplinary approaches. d. Patient feedback.
Always check with the nurse before removing any lines, tubes, or drains from the body
True False
The most helpful message to transmit about relapse to the recovering alcoholic client is that lapses
A. are an indicator of treatment failure. B. are caused by physiological changes. C. result from lack of good situational support. D. can be learning situations to prolong sobriety.