Which of the following is the most appropriate reason for using restraints on an elderly client?
1. to comply with hospital administration requirements
2. to comply with the client's family's request
3. to reduce the risk of falling
4. because the unit is understaffed
ANS: 3
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A male patient diagnosed with paranoid schizophrenia typically relates effectively with female staff but angrily tells the male nurse, "You act like a homosexual. None of the men trust you or want to be around you."
The nurse, who is heterosexual, is perplexed by the patient's statements and discusses the event with his mentor. Which explanation most likely underlies the patient's behavior? a. The patient was unleashing unconscious, hostile feelings toward the nurse. b. The patient feared the nurse would reject him, so he coped by rejecting the nurse first. c. It was the patient's way of distancing himself from potential emotional intimacy. d. The patient was coping with homosexual urges by projecting them onto the nurse.
When dealing with an alcoholic patient in denial who claims he only drinks in social situations, the nurse will:
1. insist that he stop drinking entirely. 2. point out that the patient is using denial. 3. help the client investigate ways to reduce drinking. 4. provide information on Alcoholics Anonymous.
Which patient with pain should the nurse assess first?
a. Patient with postoperative pain who received morphine sulfate IV 15 minutes ago b. Patient with neuropathic pain who has a dose of hydrocodone (Lortab) scheduled now c. Patient who received hydromorphone (Dilaudid) 1 hour ago and currently has a sedation scale of 2 d. Patient who returned from the postanesthesia care unit 2 hours ago and has a respiratory rate of 10
A patient experiences frequent recurring bouts of bipolar illness. Which member of the patient's family is likely to be most profoundly and negatively affected by the patient's illness?
a. Her mother b. Her child c. Her husband d. Her adult sister