Which is most indicative of pain in an older client who is confused? (Select all that apply.)
a. Decreased blood pressure
b. Screaming
c. Facial grimace
d. Restlessness
e. Crying
f. Decreased respirations
B, C, D, E
No one scale has been found to be the best tool to use in pain assessment for adults with cogni-tive impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations.
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The schizophrenic patient tells you, "I know that the man down the hall wants to kill me." How should you respond?
A. "I will protect you from him." B. "What makes you say that?" C. "Let's walk over here to join in afternoon activities." D. "You need to go to your room."
Rehabilitation Health Facility has a high percentage of Jewish patients recovering from a variety of ailments. Which of the following is important for the facility's staff to know about medical care and the Jewish culture?
A) Pork and shellfish but not milk products are recommended as healthful foods in the diet. B) A rabbi must be consulted before any health-related decisions can be made. C) A skullcap and socks must be worn from sundown Friday to sundown Saturday. D) Modern medical care is encouraged but may be opposed during the Sabbath.
The mental health APN is counseling with a family that he has identified as being made up of individuals who are predominantly a solid self. This means that the nurse is interacting with what type of family system?
A) Open B) Closed C) Differentiated D) Pseudocohesive
The nurse is caring for a patient who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply
1. Administer analgesics as needed. 2. Encourage the patient to ambulate to the bathroom to void. 3. Encourage leg exercises every 2 hours. 4. Encourage the patient to cough and deep-breathe every 2–4 hours. 5. Encourage the use of breathing, relaxation, and distraction.