You are caring for a client who is under 24-hour suicide watch when the client becomes very aggressive and belligerent. When you are trying to talk the client down, the client hits you. What would you recommend for this client?
A) Seclusion
B) Restraints
C) Time-out
D) Demerits
B
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Which nursing diagnosis would most likely be a priority for a client receiving a hypnotic who is experiencing confusion and excessive drowsiness in the morning?
A) Ineffective Breathing Pattern B) Risk for Injury C) Ineffective Coping D) Impaired Self Health Management
A client jumped out of a window on the second floor of the hospital and sustained a spinal cord injury that resulted in the inability to have upper and lower extremity sensation
What type of documentation by the nurse would be appropriate in this situation? A) "The client must have been depressed and wanted to commit suicide." B) "I saw the client get ready to jump and was unable to get to him fast enough." C) "Client observed standing on the window ledge; asked client to come down and proceeded to enter the room, and client jumped through the glass." D) "The previous shift should have notified the physician that the patient was suicidal."
A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take?
A. Taking the client's vital signs B. Giving the client a drink of water C. Monitoring the client for a sore throat D. Being alert to complaints of heartburn
A 68-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have any symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the nice lady, the nurse would most likely learn that the client's childhood health history included:
a. Chicken pox b. poliomyelitis c. Rheumatic fever d. meningitis