The nurse is caring for a client with delusions, hallucinations, paranoia, disorganized behavior, and difficulty relating to others. The nurse identifies these symptoms as indicative of which disorder?
1. ADHD
2. Psychosis
3. Bipolar disorder
4. Depression
2
Rationale 1:ADHD is incorrect because these are symptoms of psychosis.
Rationale 2: A client with psychosis exhibits symptoms such as delusions, hallucinations, paranoia, disorganized behavior, and difficulty relating to others.
Rationale 3:Bipolar disorder is incorrect because these are symptoms of psychosis.
Rationale 4:Depression is incorrect because these are symptoms of psychosis.
Global Rationale: A client with psychosis exhibits symptoms such as delusions, hallucinations, paranoia, disorganized behavior, and difficulty relating to others. ADHD,bipolar disorder, and depression are incorrect because these are symptoms of psychosis.
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Persons not needing parent approval for medical care would be: (Select all that apply.) a. a 14-year-old girl married to a 16-year-old boy b. a 17-year-old serving in the U.S. Navy c. a 17-year-old college freshman living in a school dormitory d. a 17-year-old seeking medical care for a sexually transmitted disease e. a 15-year-old seeking an abortion
A client who has experienced a fetal death in utero at 20 weeks asks what her baby will look like when it is delivered. How should the nurse respond to this client?
1. "The genitals of the baby will be ambiguous." 2. "Your baby will be covered in fine hair called lanugo." 3. "Your child will have arm and leg buds, but not fully formed limbs." 4. "A white, cheesy substance called vernix caseosa will be on the skin."
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection
The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. Which is the best goal for this patient? a. The patient will state what to look for with regard to an infection. b. The patient's family will demonstrate specific care of the wound site. c. The patient's family members will wash their hands when visiting the patient. d. The patient will remain free of odorous or purulent drainage from the wound.