A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client's problem?
A. The client will avoid daytime napping and attend all groups.
B. The client will exercise, as needed, before bedtime.
C. The client will sleep 7 uninterrupted hours by day four of hospitalization.
D. The client's sleep habits will improve during hospitalization.
C
The outcome "The client will sleep 7 uninterrupted hours by day four of hospitalization" is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.
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The nurse is assessing an older adult client for trauma following a motor vehicle accident. Which special considerations does the nurse understand must be taken for this client?
A) The effects of blood loss may be delayed. B) Age-related changes in cognition may increase the risk of delirium. C) A narrowed tolerance for a change in blood volume may occur. D) The description of the mechanism of injury may be delayed due to word finding difficulties.
When giving cisplatin (Platinol-AQ), the nurse is aware that the major dose-limiting effect of this drug is which condition?
a. Alopecia b. Kidney damage c. Cardiotoxicity d. Stomatitis
During a mental status evaluation, a nurse's intuition may indicate:
a. clues about the patient's physical well-being. b. subtle emotions being expressed by the patient. c. areas to be explored in the predischarge interview. d. potential nursing diagnoses that relate to a patient knowledge deficit.
The physician writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which of the following?
1. Setting the heating pad on a low setting 2. Placing the heating pad under the client 3. Assessing the heating pad periodically for proper electrical function 4. Assessing the skin integrity frequently for signs of burns