During a mental status examination, a patient shouts angrily at the nurse, "You are too nosy for your own good!" Then, almost immediately, happily says, "Well, let's let bygones be bygones and be buddies."
The nurse assesses this emotional display as: a. labile affect.
b. hallucinations.
c. magical thinking.
d. ideas of reference.
A
Lability is identified when the patient's affect shifts rapidly, such as from happy to sad or angry to elated. The remaining options are thought-content descriptors.
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The nurse assesses the client with schizophrenia and determines that which of the following demonstrates negative symptoms of the disorder?
1. The client says she is Jesus, and is preaching and baptizing. 2. Her speech is coherent, and the content is appropriate. 3. The client has a flat or very blunted affect most of the time. 4. Speech pattern is loose, moving from one idea to another.
What does the practicing nurse understand to be the most important influence on interdependent, assertive nursing practice today?
A. Higher education of registered nurses B. Improved working conditions and salaries C. Increased numbers of female physicians D. Use of the nursing process for patient care
When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated?
a. Administer oxygen by nasal cannula. b. Reposition the woman. c. Apply a fetal scalp electrode. d. Record this reassuring pattern.
Which of the following is considered objective data obtained from the patient?
a. "I can't catch my breath." b. Patient expresses concern about missing work. c. Patient nods, indicating an affirmative answer to a question. d. Blood pressure is 110/70 at 8 PM.