When the patient asks the nurse to touch him, the nurse asks why he needs this. The patient replies, "I just need to know that I am real." The nurse assesses that as a primary sign of ____________________
Fill in the blank(s) with correct word
Derealization
PTS: 1 DIF: Cognitive Level: Application REF: 1250
OBJ: 4 TOP: Derealization
KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
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What inner ear structure is affected when a patient is diagnosed with otosclerosis?
A) Malleus B) Stapes C) Incus D) Tympanic membrane
The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing?
a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 11.2 g/dL d. White blood cells 11,900/µL
After completing a scheduled every 2-hour turn by turning the patient to the left side, the nurse notices a reddened are over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area:
a) Reactive hyperemia c) Stage II pressure ulcer d) Stage III pressure ulcer
After 2 days in the PICu, e.M. is transferred back to your unit. you note that she is taking increased oral flu-
ids and requiring less suctioning. Her spo2 is 96% to 98% on room air. As you are preparing the parents for discharge, they want to know how they can prevent this in the future. They ask whether there is a "shot" e.M. can get to avoid getting this again. How would you address their concerns?