A newly admitted patient is dressed in a satin nightgown and jeweled headband. While dancing in the room and shadow boxing, the patient chants, "I'll punch you, munch you, crunch you.". Then the patient says gaily, "I am so beautiful
The entire world worships me.". How should the nurse document the patient's mood? a. Excessively happy and confident
b. Highly suspicious and arrogant
c. Unstable and unpredictable
d. Irritable and belligerent
C
The patient demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Mood swings are often rapid and seemingly without understandable reason in patients with mania.
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Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most applicable nursing diagnosis for a patient with excessively dry skin?
a. Imbalanced Nutrition: Less than body requirements b. Deficient fluid volume c. Risk for infection d. Acute pain
The nurse is transferring to a high-acuity unit where many patients receive intermittent hemodialysis. Which patient characteristic would the nurse expect?
1. Patients whose hemodynamic status requires slow removal of waste products 2. Patients whose kidney injury will resolve since intermittent dialysis is only done temporarily 3. Patients whose blood pressure and heart rate can be stabilized 4. Patients who have few imbalances in electrolyte levels
When the medication nurse offers a pill to the older adult patient, the patient asks, "What is this and what is it for?" What is the best response by the nurse?
a. "I'm not at liberty to discuss your medication. You need to talk to your doctor." b. "That's a ‘feel good' pill that will make you feel better." c. "It's a cephalosporin that has been ordered to treat your URI." d. "It's an antibiotic for the infection in your urine."
A client with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective Tissue Perfusion related to the effects of neurogenic shock
The nurse includes which of the following interventions in the client's plan of care to best address this issue? Select all that apply. 1. Utilize abdominal binder and thigh-high compression stockings. 2. Administer vasoactive agents and atropine as ordered. 3. Strictly monitor and document intake and output. 4. Administer anticoagulant medication as ordered. 5. Assess color, temperature, and size of extremities.