You enter your client's room to see her sitting in a chair, fidgeting with her hands, and looking worried. Your appropriate response would be:
1. "Would you like me to call a chaplain?"
2. "You seem distracted and nervous. Can I help?"
3. "You seem distracted and nervous. Would you like your nerve pill now?"
4. "It is time for your medicines now."
ANS: 2
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Which of the following assessment findings six hours after delivery requires immediate nursing intervention?
A) The episiotomy is slightly bruised. B) The breasts are secreting a thin, yellowish fluid. C) Lochia is dark red, and contains two nickel-sized clots. D) The mother has not voided since delivery.
The adolescent male client who weighs 100 is considering taking "some herbal stuff" to increase muscle mass and strength. The nurse should interpret this statement as an indication that this client has
1. a strong need for admiration. 2. serious problems with logical thinking. 3. incongruence between reality and ideal self. 4. the need for referral to a psychologist.
A patient with hypertension is receiving medication to lower his blood pressure. Which nursing action demonstrates the evaluation process related to medication administration?
1. Asking the patient whether he is compliant in taking his medications 2. Determining that goals were not met 3 days following medication administration 3. Administration of IV antihypertensive agents 4. Determination of the patient's baseline blood pressure
The nurse is collecting data from a patient who has a bulging eardrum. For which health problem should the nurse anticipate providing care to this patient?
a. Otitis media b. External ear infection c. Hematoma in the middle ear d. Normal tympanic membrane