A patient moving from chair to chair in the day room and pacing in the hallway repeatedly, rapidly, and for extended periods is likely demonstrating _________ , and the nurse should __________
a. a dystonic reaction…administer PRN IM benztropine (Cogentin)
b. anxiety… teach and guide the patient to use relaxation exercises
c. akathisia…administer PRN diphenhydramine (Benadryl) PO
d. tardive dyskinesia…recommend a change in medication
C
Marked, persistent psychomotor restlessness suggests akathisia, an often distressing and intense form of psychomotor restlessness. Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Anxiety often presents as motor restlessness but the inability to remain at rest is seen as frequent changes in position or location. Tardive dyskinesia involves involuntary rhythmic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis that usually appear after extended treatment and do not respond to antiparkinsonian drugs.
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a. "You can use tap water instead of sterile saline to clean your wound." b. "If you don't clean the wound properly, you could end up in the hospital." c. "Sterile procedure is necessary to keep this wound from getting infected." d. "Good hand hygiene is the only thing that really matters with wound care."
A patient is receiving oxygen therapy for pneumonia. What should the nurse assess for to determine if the patient is hypoxic?
A) Restlessness B) Cold hands C) Confusion D) Noncompliance
When recording the findings of muscle strength, a nurse records a 2 for the right arm. How should his score be interpreted?
a. Weak contraction b. Muscle movement when supported c. Active muscle movement without support d. Full, active range-of-motion exercises against resistance
Following an assessment of the client, the nurse identifies the nursing diagnosis activity intoler-ance related to increased weight gain and inactivity. An outcome identified by the nurse should be:
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