A client tried to gouge out his eye in response to auditory hallucinations commanding, "If thine eye offend thee, pluck it out." The nurse would analyze this behavior as indicating:
1. Impaired impulse control
2. Inability to manage anger
3. Derealization
4. Inappropriate affect
ANS: 1
Command hallucinations may be so intense that the client cannot control the impulse to do what the hallucination tells him to do; thus the client has impaired impulse control. 2. This is not an anger management problem. 3. Derealization is a feeling that the environment is distorted or un-real and not suggested in the scenario. 4. No evidence of inappropriate affect is given.
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The four-year-old child is undergoing cardiac surgery. To reduce the child's stress in the pre-operative period, the nurses will: Standard Text: Select all that apply
1. Explain the procedure to the child in simple terms of what the child will see, hear, and feel while awake. 2. Explain to the child that the surgery will fix her "broken" heart. 3. Allow the parents to accompany the child to the surgical holding room and wait with the child. 4. Allow the child to hold onto their special "teddy bear" while awake. 5. Wait until the child is in the holding room to insert the Foley catheter.
A family member of a patient recovering from a traumatic brain injury asks the nurse what can be done to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.)
A) Wear helmets when playing all contact sports. B) Never drive under the influence of alcohol. C) Avoid the use of throw rugs. D) Avoid skiing or riding on motorcycles. E) Wear shoes with heels when walking on ice.
During a period of cold weather, an older adult has been brought to the emergency department with suspected hypothermia. Which of the following assessments should the nurse prioritize with this client?
A) Palpation of the client's extremities to determine temperature B) Assessment of the client's level of consciousness C) Assessment of the client's core body temperature D) Interviewing to determine the client's sensation of cold
The word "calibrated" means
A) divided into sections for equal distribution to all patients. B) marked with lines and numbers for measuring. C) marked with lines and formulas for weighing. D) divided into portions for use throughout the week.