The community health nurse is visiting a client diagnosed with dysfunctional grieving since the death of his wife and child in a head-on collision over a year ago. Which of these actions should the nurse take first?
1. Facilitate expression of feelings related to the loss
2. Determine the degree of ambivalence toward the loss
3. Promote interaction with others
4. Assess risk of self-directed violence and violence toward others
ANS: 4
Safety issues are always the priority, so option 4 is correct. Options 1, 2, and 3 are appropriate actions after risk is assessed.
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A skin biopsy has been scheduled on a patient to rule out the presence of a malignancy. Which instruction should be provided to the patient?
a. A general anesthesia will be used during the procedure. b. The bandage should be changed the day after the procedure and then weekly for 2 weeks. c. The sutures placed at the site of the biopsy will be removed in approximately 10 days. d. The patient will need to be NPO 6 to 8 hours before the procedure.
Which adverse effect should the nurse monitor the client receiving doxorubicin (Adriamycin) for?
A. Neurotoxicity B. Cardiotoxicity C. Nephrotoxicity D. Hepatotoxicity
In adults, how are most intracranial tumors located?
a. Infratentorially b. Supratentorially c. Laterally d. Posterolaterally
A nurse is caring for a patient who has developed MODS (multiorgan dysfunction syndrome) resulting from septic shock. The patient is ventilator dependent and on vasopressors to maintain a Doppler-measured blood pressure of 80 mm Hg
The family is resistant to permit terminal weaning. The best action by the nurse is to a. insist that the family disconnect the pa-tient from the ventilator. b. ask the family to meet with the hospital's ethics committee. c. seek a family member who does agree and have them sign the consent form. d. arrange for the vasopressors to be turned off when the family is not present.