A patient who has schizophrenia has a dull facial expression and speaks in a monotone voice, even though a visitor is making an effort to be jovial. What terminology does the nurse use to document this observation?

a. Bored
b. Ambivalent attitude
c. Depressed
d. Flat affect

____


ANS: D
Affect is the outward expression of mood—a patient who speaks in a monotone voice and has a dull expression has a flat affect. Depression is a medical diagnosis. Documenting boredom or ambivalent attitude is subjective and should be verified with additional assessment.

Nursing

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The nurse recognizes that a patient has an inflammatory response in a surgical wound on the leg when:

a. a foul drainage is coming from the wound. b. the affected leg is cooler than the other leg. c. there are raised, red, pruritic welts on the leg. d. rubor and edema appear around the wound.

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The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area

The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a. 2800 mL b. 7000 mL c. 14 L d. 28 L

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The nurse suspects a client is developing Parkinson disease. Which early sign did the nurse most likely assess in this client?

1. Rigid posture 2. Shuffling gait 3. Masklike face 4. Tremors

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A client has been prescribed sulfasalazine (Azulfidine) for treatment of ulcerative colitis. Which nursing assessment question is essential?

1. "How long have you had ulcerative colitis?" 2. "What are you allergic to?" 3. "Are you lactose intolerant?" 4. "Do you have to stand in one place for long periods of time at your work?"

Nursing