Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care?
a. "I can always trust my family."
b. "It seems like I always have bad luck."
c. "You never know who will turn against you."
d. "I hear evil voices that tell me to do bad things."
ANS: D
The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations. The other statements are vague and do not clearly identify the patient's chief symptom.
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The nurse observes the unit clerk providing the hospital chaplain with clients' religious affiliations. The nurse's priority action is to:
1. Do nothing. 2. Stop the unit clerk and reprimand her privately for sharing privileged information. 3. Inform the chaplain that signed permission will be required to provide that information. 4. Do nothing, but speak to the unit clerk later about HIPAA privacy laws.
The nurse is transferring a patient who is in the progressive stage of shock into ICU from the medical unit. The medical nurse is aware that shock affects many organ systems and that nursing management of the patient will focus on what intervention?
A) Reviewing the cause of shock and prioritizing the patient's psychosocial needs B) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care C) Giving the prescribed treatment, but shifting focus to providing family time as the patient is unlikely to survive D) Promoting the patient's coping skills in an effort to better deal with the physiologic changes accompanying shock
A woman with type 1 diabetes recently became pregnant. The nurse plans a blood glucose testing schedule for her. What is the recommended monitoring schedule?
a. Before each meal and before bed b. In the morning for a fasting level and at 4 PM for the peak level c. Six or seven times a day d. Three times a day, along with urine glucose testing
Child has been diagnosed with a Wilms'tumor and is being treated with chemotherapy.Prior to administering the chemotherapy,the nurse will determine if this child has any infectionfighting capability by monitoring the
1. hemoglobin. 2. red-blood-cell count. 3. absolute neutrophil count (ANC). 4. platelets.