A client who is to be discharged the next day tells the nurse that once he's released he will make sure his wife will never again be able to have him committed to a psychiatric hospital. What action should the nurse take?
A. None, because no explicit threat has been made
B. Immediately cancel the client's discharge
C. Call the client's wife and report the threat
D. Report the incident to the client's therapist and document
Answer: D. Report the incident to the client's therapist and document
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In assessing for hypovolemic shock, initially the nurse will find respirations
A) shallow and slow. B) deep and rapid. C) Kussmaul and irregular. D) irregular and shallow.
Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from:
a. infection. b. arrhythmias with cardiac arrest. c. hypovolemic shock and renal failure. d. adrenal failure.
Which assessment skills could the nurse safely delegate to the unlicensed assistive personnel (UAP)?
1. Assessment of abdomen 2. Collection of nursing history 3. Assessment of client's allergies 4. Measurement of vital signs
The nurse is caring for a client who is recovering from abdominal surgery. When determining the best goal statement for the client concerning level of pain, which of the following is most appropriate?
1. The client will verbalize pain relief using an intensity rating in 4 hours. 2. The client will state that he feels fine in 4 hours. 3. The nurse will observe fewer signs of pain in the client's demeanor. 4. The nurse will reevaluate the client's pain level every 2 hours.