Which patient situation does the mental health nurse recognize may support the need for involuntary commitment?
1. History of incarceration
2. Self-medication with marijuana
3. Threats made against family members
4. Presence of auditory hallucinations
Answer: 3
Explanation: Involuntary commitment is reserved for those individuals who are dangerous to themselves or others, or who are unable to meet their own basic needs. Making threats against family members constitute a danger to others and may support the need for involuntary commitment. The patient's history of incarceration, reports of auditory hallucinations, or the use of marijuana are not factors that support involuntary commitment.
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The client's nursing diagnosis is disturbed sleep pattern related to anxiety. The desired outcome is
that the client will sleep for a minimum of 5 hours nightly by October 31 . On November 1 sleep data show the client sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. After the evaluation, the nurse should a. leave the care plan unchanged. b. remove the nursing diagnosis from the care plan. c. write a new nursing diagnosis that better reflects the problem and its cause. d. extend the time in which the goal is to be accomplished and examine interventions.
Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F
The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) a. Administer acetaminophen (Tylenol). b. Document the patient's response. c. Increase the rate of transfusion. d. Notify the blood bank. e. Notify the physician. f. Stop the transfusion.
A client has been discharged from the acute care facility with an ileostomy. The client comes to the clinic for a follow-up visit and informs the nurse that the wound has been draining and they are having abdominal pain and running a fever
What does the nurse suspect is occurring with the client? A) The client is having an allergic reaction to the appliance. B) The client has developed anemia from blood loss. C) The client has developed a wound infection. D) The client is not emptying the pouch correctly.
Which patient requires the most immediate intervention by the nurse?
1. A patient with a mandibular fracture who has facial numbness and tingling 2. A patient with a fractured nasal bone experiencing a nosebleed 3. A patient with a maxillary fracture who has been swallowing frequently 4. A patient with a temporal bone fracture experiencing hearing loss