A nurse finds a client sitting alone and crying. The most appropriate way to document this is to state:
A. Client appears depressed.
B. Client sitting alone and appears upset.
C. Client sitting alone and crying in room, states "feels bad" when asked.
D. Client not interacting with others, found obviously upset. Will refer client for evaluation and determination of problem.
C
C. Entries should be concise, factual, and accurate. This is an example of an objective description of a client's behavior.
A and B. The use of vague terms, such as appears, seems, or apparently, is not acceptable because these words suggest that the nurse is stating an opinion.
D. The nurse is making a judgment and stating an opinion. The nurse would not refer the client. This would be the physician's responsibility.
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The nurse is talking to a client who has a history of aggressive outbursts. What strategies should this nurse use? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Standard Text: Select all that apply. 1. When addressing the client, use powerful body language. 2. Remain calm and speak in a moderate tone. 3. Approach the client with an aggressive "I'm in charge" attitude. 4. Speak in simple terms. 5. Allow the client to speak.
In a client with sickle cell anemia, why does the nurse auscultate the lungs and heart?
A) To detect the abnormal sounds suggestive of acute chest syndrome and heart failure B) To detect the evidence of infection such as fever and tachycardia C) To detect the evidence of dehydration that might have triggered a sickle cell crisis D) To detect the motor strength and stroke-related signs and symptoms
An older client with a history of constipation is prescribed an opioid analgesic for postoperative pain. What should the nurse include in this client's plan of care to avoid the pain management complication of constipation? Select all that apply.
1. Mix psyllium in 4 ounces of water. 2. Provide stool softeners as prescribed. 3. Monitor for adequate daily fluid intake. 4. Increase ingestion of fresh fruit each day. 5. Offer senna tea each evening before sleep.
Which of the following strategies can be used to help patients overcome powerlessness?
A) Encourage patients to identify their weaknesses. B) Encourage patients to identify their strengths. C) Provide advice on how to handle problems. D) Set goals and make decisions for the patient.