A patient with schizophrenia approaches staff arriving for day shift and anxiously reports, "Last night demons came to my room and tried to rape me." Which response would be most therapeutic?
1. "There are no such things as demons; what you saw were hallucinations."
2. "It is not possible for anyone to enter your room at night; you are safe here."
3. "You seem very upset; please tell me more about what you experienced last night."
4. "That must have been very frightening, but we'll check on you at night and you'll be
safe."
Answer: 3. "You seem very upset; please tell me more about what you experienced last night."
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The nurse would expect to administer an anticoagulant to a patient following which surgery?
a. Hip replacement b. Hysterectomy c. Abdominal aorta aneurism (AAA) repair d. Appendectomy
An older man with myasthenia gravis lives with his wife. Which patient characteristics should the nurse use to identify areas for nursing care in the disability assessment of this man? (Select all that apply.)
a. Successfully manages his finances. b. Lives in an adults-only community. c. Walks around the house for exercise. d. Health care is provided through Medicare. e. Has a history of peptic ulcer disease. f. Wife is in good health but has poor eye-sight.
A client with a laparoscopic cholecystectomy is complaining postoperatively of shoulder pain and is asking if the surgical team incorrectly positioned the client when in surgery
The nursing diagnosis for this client is Comfort: Readiness for Enhanced. A nursing intervention that is appropriate for this client is: 1. Provide a warm pack to the shoulder and ambulate the client, progressing to the client's prior activity level. 2. Provide pain medication for breakthrough pain unrelieved by the PCA morphine. 3. Provide an antiemetic as ordered. 4. Examine the abdomen for sign of peritonitis.
The nurse has instructed an older patient on the modified My Plate and caloric intake. Which patent response indicates that instruction has been effective?
1. "If I consume the lowest daily recommended value for all of the food groups, it will result in approximately 2,000 calories." 2. "If I consume the lowest daily recommended value for all of the food groups, it will result in approximately 1,600 calories." 3. "If I consume the lowest daily recommended value for all of the food groups, it will result in approximately 2,200 calories." 4. "If I consume the lowest daily recommended value for all of the food groups, it will result in approximately 2,400 calories."