The nurse records the following data about a client: "Client has not spoken despite repeated efforts
to elicit speech by nurse and other staff.
Makes no eye contact and is inattentive to staff who attempt
to engage him, gazing off to the side or looking upward rather than at speaker.". A possible nursing
diagnosis that deserves more investigation is
a. defensive coping.
b. risk for violence.
c. decisional conflict.
d. impaired verbal communication.
ANS: D
The defining characteristics are more related to the nursing diagnosis of impaired verbal
communication than to the other nursing diagnoses.
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The nurse is planning care to address a patient's spiritual distress. Which interventions would be appropriate to include in this plan of care? (Select all that apply.)
A) Pray with the patient upon request as needed and desired B) Find a volunteer to read the Bible to the patient upon request C) Remind the patient that spiritual needs are often addressed last D) Contact the patient's church to have the clergy visit the patient E) Help the patient identify factors contributing to spiritual distress
The patient is being considered for treatment with the drug metformin (Glucophage). The health care provider recognizes that a contraindication to use of this drug with this patient would be his history of:
a. Asthma b. Chronic bronchitis c. Renal disease d. Enlarged prostate
A phenomenological research question might be which of the following?
a. How do different cultures adapt to breast-feeding multiple infants? b. How many mothers of twins elect to breast-feed their infants? c. What is it like to breast-feed twins? d. What past events have led many women to avoid breast-feeding?
During a head and neck assessment, the nurse notes that the client's neck is enlarged, which is later confirmed to be due to a goiter. The client's serum thyroid levels are within normal limits. Which type of goiter does the nurse suspect?
A) Toxic multinodular goiter B) Endemic goiter C) Nontoxic diffuse goiter D) Chronic autoimmune thyroiditis