A 32-year-old woman comes to the emergency department after being raped. Her language and behavior are disorganized, and it is difficult to understand her. Her pulse is 120 beats per minute, and her respiratory rate is 20 breaths per minute
She keeps saying, "He wore a ski mask," over and over in a loud voice. Which of the following is the best stress-related nursing diagnosis for the client at this time?
1. Defensive coping
2. Ineffective coping
3. Ineffective denial
4. Situational low self-esteem
ANS: 2
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A critically ill patient with a Hispanic and American Indian ethnic background is in hemorrhagic shock. The nurse notices that the patient's skin is yellowish brown and the conjunctiva, oral mucosa, and nail beds are ashen gray
What variation in skin color does the nurse document? A) Pallor B) Cyanosis C) Jaundice D) Erythema
The nurse is preparing discharge instructions for an older adult client recovering from respiratory acidosis caused by restrictive lung disease and pneumonia. Which topics should the nurse include in the discharge teaching for this client?
Select all that apply. A) Obtain annual influenza immunization. B) Engage in frequent hand washing. C) Avoid crowds. D) Cover the nose and mouth when coughing. E) Restrict fluids.
The nurse has completed a shift assessment on a client who has terminal breast cancer with extensive metastasis. The client tells the nurse, "Nothing helps the pain." What best describes the pain being experienced by the client?
1. The client is experiencing referred pain. 2. The client is experiencing intractable pain. 3. The client is experiencing retractable pain. 4. The client is experiencing radiating pain.
A 58-year-old male prescribed testosterone
replacement is married to a 34-year-old woman who is expecting their first child. What safety measure would you teach the patient and his wife? a. "Wear a condom if you have sex with your wife at any time while she is pregnant." b. "Do not touch linens that have been in contact with your husband's testosterone gel." c. "Never enter the bathroom while your husband is applying the testosterone gel." d. "Avoid high protein containing foods because they can interact with the testosterone gel."