During the first interview, a nurse notices that the patient does not make eye contact. The nurse can correctly analyze that:
a. the patient is not truthful.
b. the patient is feeling sad.
c. the patient has a poor self-concept.
d. more information is needed to draw a conclusion.
ANS: D
The data are insufficient to draw a conclusion. The nurse must continue to assess.
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A 7-year-old child has been seen in the pediatric clinic three times in the last two months for complaints of abdominal pain. Physical exam and all ordered lab work have been normal
The statement by the nurse working with this child that would be most likely to help determine the etiology of this child's abdominal pain is: 1. "Have there been any changes in your child's school or home life recently?" 2. "Tell me what your child usually eats on a normal day." 3. "Are your child's immunizations up to date?" 4. "Has your child had any fevers or viral illnesses in the last three months?"
A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first?
a. Reassure the client that the voice change is temporary. b. Document the finding and assess the client hourly. c. Place the client in high-Fowler's position and apply oxygen. d. Contact the provider and prepare for intubation.
When a patient is asked whether he wants his pain medication, he says to you, "I don't know; whatever you think is best." What should the nurse recognize this maladaptive coping mechanism as?
a. Powerlessness b. Helplessness c. Denial d. Depression
A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient? Place in order the steps of the process.Choice 1. Stop the transfusion and notify the healthcare providerChoice 2. Compare the blood slip with the unit of bloodChoice 3. Assess vital signs and associated manifestationsChoice 4. Save the blood bag and tubing for laboratory analysisChoice 5. Collect urine and venous blood samples according to policy
Fill in the blank(s) with the appropriate word(s).