A young adult client is admitted to the psychiatric unit after a suicide attempt. The nurse learns that the client recently escaped from a domestic violence situation and was sexually abused by a parent as a child
The nurse observes that the client has numerous cuts up and down both arms and legs. After more discussion, the nurse writes the following diagnosis in the client's care plan: Self-mutilation related to need to end dissociative experiences, secondary to sexual abuse. What did the client say that was evidence for this diagnosis? A) "Cutting myself was the only way I could get admitted to the hospital.".
B) "I cut when I get angry at myself; it feels like something I deserve.".
C) "When I cut myself I feel alive, not like a lump of dead meat.".
D) "I have periods where I feel like I am living in a dream or walking through a fog and cutting helps me
refocus.".
D
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A nurse notes that the urethral catheter of a client who had prostate cancer surgery is draining dark bloody urine with clots, but the tubing is not draining freely. Which action should the nurse take FIRST?
a. Call the health care provider immediately. b. Increase the tension on the catheter by retaping. c. Irrigate the catheter with 150 cc of sterile normal saline. d. Milk the tubing.
The nurse is discussing adverse effects of
antitubercular drugs with a patient who has active tuberculosis. Which potential adverse effect of antitubercular drug therapy should the patient report to the prescriber? a. Gastrointestinal upset b. Headache and nervousness c. Reddish-orange urine and stool d. Numbness and tingling of extremities
When making an assessment of the client's learning needs, the nurse will focus on which elements?
1. Nurse's own knowledge. 2. Client's age. 3. Client's understanding of health problem. 4. Sensory acuity. 5. Learning style.
A patient diagnosed with a symptomatic urinary tract infection (UTI) is prescribed phenazopyridine (Pyridium). What should the nurse instruct the patient about the color of the urine?
A. It will become clearer and pale yellow. B. It will turn brown. C. It will have a green tint. D. It will become orange or red.