A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient's:
a. Affect and mood
b. Memory and affect
c. Language abilities
d. Level of consciousness and cognitive abilities
ANS: D
Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. Delirium is not an alteration in mood, affect, or language abilities.
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The nurse understands that during the Tension Building Phase of the Cycle of Violence, victims may protect themselves by exhibiting which of the following behaviors? Select all that apply
A) After the abuser apologizes, expressing hope about the future B) If possible, leaving the abuser alone C) Taking actions to calm the abuser D) Welcoming the idea to have someone else contact the authorities E) Attempting to nurture the abuser
A client is prescribed antiembolic stockings. How should the nurse assess the skin on the client's legs?
1. Defer the assessment because the stockings are in place. 2. Remove the stockings for this assessment. 3. Review the morning assessment, but don't repeat it unless a problem occurs. 4. Assess the skin when the client removes the stockings at bedtime.
A client calls the clinic and tells the nurse that she has missed taking several of her contraceptive pills during the current cycle. What is the best instruction for the nurse to give the client?
1. "Please come into the clinic immediately to have a pregnancy test done." 2. "You might consider another form of birth control if you keep missing your pills." 3. "If you have missed less than three of your pills, you do not need to worry." 4. "You should use an alternative form of birth control for the rest of this cycle."
A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago
A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. The nurse should: 1. Keep the problem on the care plan, in case the symptoms return. 2. Document that the problem has been resolved and discontinue the care for the problem. 3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met. 4. Document that the potential problem is being prevented since the symptoms have stopped.