A nurse assesses a 91-year-old client in long-term care healing from bilateral broken legs caused in a fall. Today, the client developed new onset confusion and combativeness
Which of the factors must the nurse investigate as a source of this mental status state? (Select all that apply.)
A) Social separation
B) Hyponatremia
C) Medication interactions
D) Positional pain
E) Urinary tract infection
Ans: B, C, E
Sodium level, medications, and urinary tract infections can each lead to confusion and combativeness. While pain and social separation may be associated with confusion, they are unlikely to be the root cause of these new onset issues.
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During descent, an airplane passenger is complaining that his "ears are plugged." What aspect of the structure and function of the ear best accounts for the passenger's complaint?
A) The inner ear adjusts its volume in response to atmospheric pressure, increasing during low pressure and decreasing in high pressure. B) The eustachian tubes must remain patent to equalize pressure between the middle ear and inner ear. C) The tympanic membrane is selectively permeable in order to accommodate pressure changes, and this capacity is often impaired during upper respiratory infections. D) Air must be able to flow between the middle ear and nasopharynx in order to accommodate pressure changes.
The nurse is having difficulty developing nursing diagnoses for a client because of incomplete assessment data. A problem with assessment data may be that the:
a. data is comprehensive. b. client may be unwilling to share data. c. complete validation is needed. d. nursing diagnosis is clear.
On which of the following components is Rosenstock's health belief model based? Select all that apply
A) Perceived susceptibility to a disease B) Perceived consequences of treating disease C) Perceived seriousness of a disease D) Perceived benefits of action E) Perceived immunity to disease
During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months."
How should the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent