A severely depressed patient lost 20 pounds over the past month, has chronic low self-esteem, and the intent and a plan for suicide. The patient has taken an antidepressant medication for 1 week
The nurse adds this outcome to the plan of care: Patient will refrain from gestures and attempts to harm self. Which nursing intervention is most directly related to this outcome? a. Implement suicide precautions
b. Offer high-calorie snacks and fluids frequently
c. Assist the patient to identify three personal strengths
d. Observe patient for therapeutic effects of antidepressant medication
A
The intervention should relate to patient safety. The other options, related to nutrition, self-esteem and medication therapy, are important but not a priority.
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Pigmented, raised, warty lesions over the face and trunk should be assessed by an experienced practitioner who can distinguish:
a. cutaneous tags from lentigines. b. furuncles from folliculitis. c. sebaceous hyperplasia from eczema. d. seborrheic keratoses from actinic keratos-es.
The nurse is providing teaching for the family of a patient who has been newly diagnosed with Alzheimer's disease (AD). Which statement by the family member indicates understanding of the teaching?
a. "Alzheimer's disease is a chronic, progressive condition." b. "Alzheimer's disease affects memory but not personality." c. "The onset of Alzheimer's disease is usually between 65 and 75 years." d. "With proper treatment, symptoms of this disease can be arrested."
A nurse identifies that a client is in Phase 4 of the developmental stages of a crisis. Which symptoms should the nurse anticipate when caring for this client?
A) The individual may try to view the problem from a different perspective, or even to overlook certain aspects of it. B) Cognitive functions are disordered, emotions are labile, and behavior may reflect the presence of psychotic thinking. C) The client has developed anxiety. D) Feelings of confusion and disorganization prevail.
From an assessment, the nurse learns that the client is having difficulty sleeping because of pain in the hips and knees due to arthritis. The client is weak and fatigued. Which diagnoses would be applicable to the client at this time?
1. Anxiety 2. Hopelessness 3. Ineffective Health Maintenance 4. Insomnia 5. Impaired Physical Mobility