A 16-year-old boy who is positive for the human immunodeficiency virus (HIV) confesses to the school nurse that he sneaks out of his home at night and rides his motorcycle at high rates of speed. How should the nurse interpret this behavior?
a. An attempt at manipulation
b. Striving for identity
c. Defiance of impending death
d. A normal teenage prank
C
Teenagers between the ages of 13 and 18 years may act out with dangerous or risky behavior in defiance of death.
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Which of the following instructions should a nurse provide as the single most important measure to prevent the spread of infection?
A) Minimal social contact C) Thorough hand washing B) Regular immunizations D) Sufficient food intake
For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Select all that apply
a. Talk to the patient as you provide care. b. Incorporate more touch in the plan of care. c. Give frequent eye care if blink reflex is absent. d. Keep the siderails up and bed in low position. e. Perform diligent oral care by irrigating with diluted mouthwash.
A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of risk for injury related to decreased vision. Based on this assessment, the cli-ent will benefit the most from:
1. Installing fluorescent lighting throughout the house 2. Becoming oriented to the position of the furniture and stairways 3. Maintaining complete bed rest in a hospital bed with side rails 4. Applying physical restraints
Toward the end of your visit, P.C. looks at you and says, "You know, I just really thought I had
more time." The most appropriate response is: a. "Dying is a natural process; we will help you through it." b. "Your feelings are understandable; most people aren't ready to die." c. "Tell me more about what you mean when you say, 'I thought I had more time.'" d. "No one ever really knows when it is their time, even if they don't have cancer."