In nursing rounds, the charge nurse shares with the group that a client, who was admitted last night, is a 59-year-old male with hypertension. This is his first psychiatric hospitalization
The behaviors on admission were "suspiciousness and agitation." The information shared may be considered a part of the nursing: a. evaluation
b. assessment
c. goals
d. intervention
B
Assessment in psychiatric nursing involves information obtained on admission. This would include both subjective data obtained by the client and objective data that the nurse has obtained. Information is obtained from the interview and the client history and physical examination.
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The nurse would expect a client who is exhibiting the vegetative signs of depression to have:
1. Constipation and insomnia. 2. Helplessness. 3. Hopelessness. 4. Suicidal ideation and a plan.
The LPN is leading a cardiac rehabilitation support group. How can the nurse best demonstrate meeting the clients need holistically?
A) Lead an exercise, show a video about healthy lifestyle changes, and invite a spiritual leader to talk with the group. B) Have the clients share various healthy low-cholesterol recipes and participate in a cooking class. C) Have the clients discuss ways to relieve stress and practice stress reduction. D) Demonstrate low-impact aerobic exercise to the group and bring in a lecturer on Tai Chi.
Evidence-based practice relies on rigorous integration of research evidence on a topic through systematic reviews. What is a systematic review?
A) Use of carefully developed sampling and data collection procedures that are spelled out during data collection B) Use of methodically integrated data collection procedures that are spelled out during data collection in a protocol C) Use of carefully developed sampling and data collection procedures that are spelled out in advanced in a protocol D) Use of methodically integrated data collection procedures that are spelled out during data collection
The nurse documents a patient's radial pulse rate as 120 beats/min and regular. One hour later, the nurse rechecks the pulse and it is irregular at 120 beats/min. What is the most appropriate nursing action?
a. Ask another nurse to check the pulse. b. Place the patient on bedrest and administer fluids. c. Place the patient on a cardiac monitor. d. Check the pulse in the opposite arm.