After being diagnosed with cancer, the patient appears angry. At this point it would be appropriate for the nurse to assess for which kind of distress?
a. Environmental
b. Developmental
c. Physical
d. Spiritual
ANS: D
ANS: D
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A family member expresses concern to the nurse about behavioral changes in an elderly client. What information would cause the nurse to suspect a dementia disorder?
1. Decreased enjoyment of activities that were once enjoyable 2. Problems with preparing a meal or balancing a checkbook 3. Increased complaints of physical ailments 4. Sudden disturbed sleep–wake cycle
The nurse should clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula at least every:
a. 2 hours. b. 6 hours. c. 8 hours. d. 10 hours.
A nurse is administering Debrox to a client with excess cerumen. Which of the following conditions may have prompted this treatment?
A) Ear wax accumulation leading to hearing loss B) Tan to black raised areas on the trunk C) Brown, flat patches on the face D) Tooth loss and inflammation of the gums
When planning care for a client receiving treatment for vomiting, the nurse's highest priority nursing diagnosis is:
a. prevention of aspiration by placing client in lateral position. b. risk for aspiration related to vomiting. c. nausea related to receiving chemotherapy. d. risk for deficient fluid volume related to vomiting.