A client has begun to neglect her appearance, is withdrawn and stays in her room. Her mother hears her seemingly talking to others, but no one is in the room with her. Last night she threw a chair and broke the window of her bedroom. She tells the nurse nothing is wrong. The nurse rating her current global assessment of functioning would probably assign the code
a. 100.
b. 70.
c. 40.
d. 0.
Ans: c. 40.
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A client was admitted to home care and was dismayed to find the nurse discussing such uncomfortable topics as advance directives, living will, and durable power of attorney. Which of the following is the most appropriate response by the nurse?
a. "Don't be concerned; this is just routine." b. "I'm sorry, but the state law says I have to ask you to fill out these forms." c. "You get to make decisions about your care, but if, for any reason, you can't do this, these forms will tell us what you want us to do." d. "Your physician asked us to discuss these with you."
Prior to the administration of methylergonovine, the nurse needs to assess the maternal
a. temperature c. blood pressure b. pulse d. perineum
The three stages of swallowing are the _____ phases
a. early, middle, and late b. oral, laryngeal, and epiglottal c. bolus, pharyngeal, and posterior d. oral, pharyngeal, and esophageal
During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. What would the nurse's priority action be?
1. To help the fetal head descend faster 2. To use gravity and manipulation to relieve compression on the cord 3. To facilitate dilation of the cervix with prostaglandin gel 4. To prevent head compression