A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do?
a) add a placebo to the morphine to appease the spouse
b) discuss with the spouse the risk for morphine addiction
c) assess the client's pain before increasing the dose of the morphine
d) check the client's heart rate before increasing the morphine tto the next level
Answer: c) assess the client's pain before increasing the dose of the morphine
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An elderly patient with multi-infarct dementia is striking out with her arms and kicking at people who walk past in the hall. The nurse determines that the patient believes she is at home and that the other patients have broken into her home
The clinical nurse specialist suggests that staff use validation. Which of the following responses reflect this intervention? a. "I'm a nurse who has come to check on you. Tell me about your home.". b. "You are in a nursing home. The others here are patients, just like you are.". c. "I wish you could be home, but you have been sick and are in a nursing home.". d. "You are not at home. This is a nursing home. It is September 10th, 2010.".
The patient at 9 weeks' gestation has been told that her HIV test was positive. The patient is very upset and tells the nurse, "I didn't know I had HIV! What will this do to my baby?" The nurse knows teaching has been effective when the patient states:
1. "I cannot take the medications that control HIV during my pregnancy because they will harm the baby." 2. "My baby will probably be born with anti-HIV antibodies, but that doesn't mean it is infected." 3. "The pregnancy will increase the progression of my disease and will reduce my CD4 counts." 4. "The HIV won't affect my baby, and I will have a low-risk pregnancy without additional testing."
The nurse leader of a large long-term care facility is aware that different leadership styles are appropriate in different situations. Which situation should warrant the application of authoritarian leadership principles?
A) The existing process of making nursing assignments needs to be reexamined. B) It has just come to the attention of staff that a resident is missing. C) The nurse manager has been informed that there will be a budget reduction for the next year. D) There have been communication problems between nurses and unlicensed assistive personnel in recent weeks.
A nurse is reviewing progress notes on a newly admitted client. One progress note reveals that the client purposefully inserted a contaminated catheter into urethra, leading to a urinary tract infection
The nurse recognizes this behavior as characteristic of which mental disorder? 1. Illness anxiety disorder 2. Factitious disorder 3. Functional neurological symptom disorder 4. Depersonalization-derealization disorder