The nurse is utilizing limit-setting with a client. The nurse recognizes the potential benefit of limit-setting as which of the following?
A) An absence of privileges during therapy
B) A decrease in decision-making capability
C) A promotion of moderate anxiety
D) A minimization of manipulation
Ans: D
Limit-setting reduces anxiety, minimizes manipulation, provides a framework for client functioning, and enables the client to learn to make requests. Choices are provided whenever possible. Privileges are taken away if the client does not follow the rules or regulations.
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When assessing a patient for signs of hypoxemia, which of the following should the nurse interpret as a late sign?
A) Increased respiratory rate B) Increased heart rate C) Diaphoresis D) Agitation
The postoperative cardiac surgery client has an accumulation of fluid in the pleural space 2 weeks after surgery. Which term will the nurse use to explain this condition to the client and family?
1. Pneumothorax 2. Hemothorax 3. Pleural effusion 4. Pulmonary edema
After being informed that their father has experienced a stroke that has affected a portion of his cerebrum, the patient's family asks the nurse, "What effect will aphasia have on his life?" How should the nurse respond?
1. "He will likely become depressed until he adjusts to the dysfunction." 2. "You'll have to speak very loudly when you talk." 3. "The way he communicates with you will change." 4. "Perhaps you should learn about the different options for speech therapy."
The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. What is one of the easiest ways to prevent a pressure ulcer from occurring in an im-mobile client?
a. Keep the skin dry. b. Provide range-of-motion exercises every shift. c. Use lift equipment when transferring a client. d. Turn the client a minimum of every two hours.