A client admitted with injuries after being involved in a motor vehicle crash states to the nurse, "every time I close my eyes I see the truck coming." Which is the priority nursing diagnosis for this client?
A) Post-Trauma Syndrome
B) Risk for Infection
C) Ineffective Coping
D) Anxiety
Answer: A
The client is reliving the motor vehicle accident every time she closes her eyes. This indicates that the client is at risk for or has developed post-trauma syndrome. There is not enough information to determine whether the client is at risk for infection, ineffective coping, or anxiety.
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A) Convince the boy that the medication is actually a treat, especially reserved for him. B) Mix the medication with pleasantly flavored syrup or pureed fruit. C) Withdraw some of the child's privileges if he refuses to take his medication. D) Distract the child with a toy and then put it in his mouth quickly.
Ms. Green is an 85-year-old female patient with dementia who presents to the emergency department with her daughter because of a change in function. Which pain assessment scale would be the best choice?
a. Oucher Scale b. Checklist for Nonverbal Pain Indicators c. Wong/Baker Rating Scale d. CRIES Scale
When a client states, "Suicide is the only thing that will help," the nurse knows which of the following? Select all that apply
A) Take the bereaved on family outings for a year. B) Listen carefully and take all suicide talk seriously. C) Involve the family in a bereavement support group. D) Involve families in psychoeducational and family network services. E) Not try to talk the client out of suicidal intentions.
A nurse is preparing to assist the physician in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination?
A. Prone B. Left side-lying C. Sims D. Lithotomy