Three policemen bring a client to the mental health unit. She had been directing traffic and shouting rhymes on a busy city street. Her husband reported that the client had stopped taking her lithium 3 weeks ago and had not slept or eaten for 3 days. Which behaviors listed below will be of priority concern as the nurse begins a care plan for the client?
a. Bizarre, colorful, inappropriate dress
b. Grandiose thinking, poor concentration
c. Insulting, provocative behavior directed at staff
d. Hyperactivity, ignoring eating and sleeping
d. Hyperactivity, ignoring eating and sleeping
Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed
above because they threaten the physical integrity of the client. The other behaviors are less
threatening to the client's life.
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An operating room nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. Which of the following is an action of this medication?
A) It promotes induction of anesthesia. B) It decreases gastric acidity and volume. C) It promotes sleep or conscious sedation. D) It decreases respiratory secretions.
When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician?
A) "I haven't had anything to eat or drink since midnight last night." B) "I really don't like to be in small, enclosed spaces." C) "I left all my jewelry and my watch at home." D) "I brought earphones to shut out the loud noise."
Which term describes irregular areas of deep blue pigmentation seen predominantly in infants of African, Asian, Native American, or Hispanic descent?
a. Acrocyanosis b. Mongolian spots c. Erythema toxicum d. Harlequin color change
A client comes to day treatment intoxicated, but says he is not. The nurse identifies that the client is exhibiting symptoms of
a. denial. b. reaction formation. c. projection. d. Transference