A nurse documents: "Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker." Which nursing diagnosis should be considered?
a. Defensive coping
b. Decisional conflict
c. Risk for other-directed violence
d. Impaired verbal communication
ANS: D
The defining characteristics are more related to the nursing diagnosis of Impaired verbal communication than to the other nursing diagnoses.
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An older male adult who had a gastric resection states that he wants to ambulate but the osteoarthritis (OA) in his knees causes too much pain. Which intervention should the nurse implement to increase the amount of walking this man performs?
a. Encourage pain medication around-the-clock. b. Instruct him to rest until the pain disappears. c. Suggest taking pain medication before walking. d. Collaborate with health care provider to provide a walker.
The nurse is explaining fetus viability to a client considering terminating her pregnancy. The nurse explains that a fetus is usually considered viable and can survive with medical interventions at how many weeks' gestation?
a. 16 c. 24 b. 18 d. 28
Which jugular vein pulsation results from the slow buildup of blood in the right atrium during ventricular contractions?
a. a wave c. g wave b. c wave d. v wave
The client who underwent a nephrolithotomy procedure 24 hours ago now has a fever of 101° F. What is the nurse's best action?
A. Apply a cooling blanket. B. Strain the urine. C. Notify the physician. D. Document the finding as the only action.