A patient tells the nurse, "I want to have sex with you." Which nursing responses are appropriate? Select all that apply
a. "I will forget you said that."
b. "Your suggestion frightens me."
c. "You must keep your distance."
d. "Sex is not part of our relationship."
e. "We are here to work on your problems."
D, E
The correct responses provide information to the patient about the purpose of the relationship and recognize the underlying need. The other options are ineffective.
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The nurse is teaching a group of patient about diseases such as Rocky Mountain Spotted Fever that are transmitted by ticks. The nurse's explanation would be correct if she states that the tick functions as:
a. vectors. b. bacteria. c. viruses. d. fungi.
A patient is prescribed an angiotensin-converting enzyme (ACE) inhibitor, enalapril (Vasotec). What is an appropriate instruction for the nurse to provide?
a. Monitor potassium intake. b. Report asthma symptoms. c. Return for follow-up visits. d. Assess blood sugar closely.
The results of a total serum bilirubin test done on an infant at 52 hours old is 14 milligrams per deciliter. What is the most appropriate initial nursing action?
a. Contact the physician promptly for further orders. b. Prepare for immediate exchange transfusion. c. Discontinue breastfeeding, and start soy-based formula. d. Repeat the test for clarification.
An important action the nurse can take that will most likely increase client compliance with a sodium- and fat-restricted diet is to
a. offer to find the client a class on heart-healthy cooking. b. provide verbal education on ways to modify the client's current diet. c. refer the client for a consultation with a registered dietitian. d. tell the client about complications that may occur from not being compliant.