Bruce is a nurse working for a postsurgical unit. He is caring for five postsurgical patients, and one patient who is awaiting surgery. About which of the following patients should he be most concerned regarding a health care-associated infection?
A. 78-year-old man with bacterial growth in his urine
B. 19-year-old man with a white blood cell count of 10,000/mm3
C. 23-year-old woman one day postoperative with redness at incision site
D. 35-year-old woman with temperature of 99.3° F and complaints of malaise
D
Objective data such as an elevated temperature, open draining wound, inflammation of a wound site, and laboratory values revealing an increased white blood cell count indicate an actual infection. Subjective findings include the patient's complaint of chills, malaise, or tenderness at the wound site. When assessing laboratory data, consider the age of the patient. For example, in an older adult, bacterial growth in urine without clinical symptoms does not always indicate the presence of a urinary tract infection.
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A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include:
a. aloofness, increased distractibility, and suspicion. b. elevated mood, hypertalkativeness, and distractibility. c. performing rituals and avoiding open places. d. darting eyes, distracted, and mumbling to self.
A pilot study (Beebe, 2006 ) of eleven veterans living with schizophrenia, obesity, diabetes, and/or stroke in the southeastern United States found a correlation between schizophrenia and:
A) Poor physical health. B) Drug overdose. C) Accidents. D) Negative symptoms.
What is a secondary source for a research literature review?
A) A description of a study written by researchers who did the study B) A summary of relevant research on the topic of interest C) A thesaurus that directs readers to subject headings germane to the topic D) A description of the study by an individual unconnected with it
A schizophrenic client says to the nurse, "I keep getting these thoughts and hearing voices. They worry and consume me so that I can't always stop myself like my health care provider told me to." Which intervention would the nurse suggest as a distraction technique?
A. "Pretend that you're on the phone and talk to the voices." B. "Have you tried to count back from 100 or listen to music?" C. "The next time this happens, try telling the voices to go away." D. "Tell the voices that you will only listen to them just before you watch television at 8:30 in the evening."