Which nursing diagnosis would likely apply to both patients with paranoid schizophrenia and patients with amphetamine-induced psychosis?
a. Powerlessness
b. Disturbed thought processes
c. Ineffective thermoregulation
d. Impaired oral mucous membrane
ANS: B
Both types of patients commonly experience paranoid delusions; thus the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.
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A psychiatric nurse leads a medication education group for Hispanic patients. This nurse holds a Western worldview and uses pamphlets as teaching tools. Groups are short and concise. After the group, the patients are most likely to believe:
a. the nurse was uncaring. b. the session was effective. c. the teaching was efficient. d. they were treated respectfully.
The nurse is caring for a patient in a wound clinic who is treated with plastic wrap dressings. Which of the following findings indicate complications related to prolonged application of the dressings? (Select all that apply.)
a. Cyanosis b. Maceration c. Skin atrophy d. Folliculitis e. Lichenification f. Hyperpigmentation
Which of the following is the primary factor in how a hospice nurse makes decisions while giving care in the client's home, surrounded by the client's family?
a. To allow the patient a comfortable, pain-free death b. To assure the caregiver and the whole family that they are not hastening the client's death by anything they do to keep the client comfortable c. To encourage the family to grieve and confront the reality of the client being terminal d. To prevent a decline in the caregiver's health made considering the health of the caregivers. Encouragement of the family to grieve and confront the reality of the client being terminal would not be a primary factor in how the nurse makes decisions.
A patient comes into the emergency department after being injured in an automobile crash in which a semi-truck hit her car from behind. The nurse will assess this patient for findings associated with which type of injury?
1. Ankylosing spondylitis 2. Axial loading 3. Hyperflexion 4. Hyperextension