A 12-year-old client has been diagnosed with dissociative identity disorder. Nurses gathering
assessment data should be particularly alert to references that may relate to
a. low socioeconomic status.
b. lack of cultural role models.
c. physical or sexual abuse.
d. parental marital discord.
C
Physical or sexual abuse of children puts them at risk for developing dissociative identity disorder as
a defense against anxiety associated with the abuse. Although the other options cause increased
social and environmental stress for children, these stressors do not seem to predispose to dissociative
identity disorder.
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The nurse is caring for an older patient with chronic obstructive pulmonary disease (COPD) who is having difficulty clearing secretions from the respiratory tract
Which actions can the nurse take to help this patient? Standard Text: Select all that apply. 1. Restrict oral fluids. 2. Use postural drainage. 3. Apply chest percussion. 4. Teach controlled coughing. 5. Perform tracheal suctioning.
A client asks the nurse how she can tell if labor is real? What should the nurse give as an explanation? (Select all that apply.)
a. In true labor, the cervix begins to dilate. b. In true labor, the contractions are felt in the abdomen and groin. c. In true labor, contractions often resemble menstrual cramps during early labor. d. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages. e. In true labor your contractions tend to increase in frequency, duration, and intensity with walking.
A nurse is caring for a client who is receiving hemodialysis. During dialysis, what
measure should the nurse or the dialysis nurse employ when caring for this client? A) Check the shunt every 20 to 30 minutes for vibration B) Measure blood pressure on the non-dominant arm C) Encourage the client to drink enough orange juice D) Keep two clamps on the dressing over the cannula
The nurse is assessing a client's blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data:
1. Reflect a normal variation 2. Should be reported to the client's health care provider 3. Dictate that pressure should be monitored in the left arm 4. Indicate that the client may be experiencing vascular problems