The nurse has planned to confront the client about illicit drug use that occurred when the client was given a pass to leave the hospital the previous day
As the nurse enters, the client is sobbing and the nurse learns that the client's mother has been hospitalized with a stroke. Which factor will have the greatest influence on modifying the planned interaction?
1. Environmental factors
2. Knowledge
3. Relationship
4. Attitude
ANS: 1
Environmental factors include timing. Timing of confrontation about drug use is important. It should occur when the individual can give full attention to the topic. It would be inappropriate to continue with the plan in the face of the client's distress related to her mother's illness. Options 2, 3, and 4 are factors of lesser influence in this situation.
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An older patient being treated for pneumonia is given a sedative to sleep. A few hours afterwards, the patient has a respiratory rate of 12 and cannot be aroused. What does this assessment finding indicate to the nurse?
1. The sedative was not absorbed. 2. The sedative has reached a therapeutic blood level. 3. The medication for sleep caused excessive sedation. 4. The patient is experiencing complications of pneumonia.
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate?
A) "Everything will be fine. Your family is here for you." B) "Don't cry; you have the best team of doctors." C) "Would you like something to calm your nerves?" D) "Tell me what concerns you most."
The person who is unable to identify time, place, or person to the point that he or she is unable to make appropriate decisions is described as __________
Fill in the blank with the appropriate word.
After reviewing the lab results for the clients to which the nurse is assigned, select the client the nurse should assess first
a. 53-year-old man with a CPKMB of 3% b. 33-year-old man with a cTnT2 of 0.8 ng/mL c. 48-year-old woman with a LDH1 of 25% d. 64-year-old woman with a triglyceride level of 175 mg/dL