An older patient dying of end-stage pulmonary disease and dementia receives narcotic medication for chronic pain. Currently the patient is restless and grimacing. How should the nurse interpret these assessment findings?
1. The patient is in pain.
2. The patient has an undiagnosed personality disorder.
3. The patient needs nonpharmacological pain management approaches.
4. The patient is not experiencing any difference in pain level and no adjustments are needed.
1
Rationale: When an older adult is unable to speak or self-report the level of pain, the nurse should carefully observe the patient for behavioral symptoms of pain that may include restlessness and grimacing.
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During the auscultation of a patient's heart sounds, the nurse hears a fixed S2 split. What does this heart sound indicate to the nurse?
A) Pulmonic stenosis B) Right bundle branch block C) Right ventricular failure D) Left bundle branch block
The informatics nurse is assisting with the analysis of a clinical information system for a multisystem healthcare organization. Which characteristics of data should the nurse ensure are present to support quality patient care? Select all that apply.
A) Absent of bias and current B) Clear, accurate, and available C) Precise and verified by other means D) Documented in more than one place E) Limited use of health information exchange
The nurse is teaching management of type 2 diabetes mellitus to a group of older adults. Which participant statement indicates that additional instruction is needed?
1. "I will keep some hard candy with me at all times." 2. "I will start a walking program with my neighbors." 3. "If I'm sick, I will call my doctor to see if I should take my medicine." 4. "If I start to feel nervous, sweaty, or shaky, I will drink a glass of water."
In which circumstance would a psychiatric forensic nurse examiner determine it appropriate for a defendant and attorney to consider the insanity defense? At the time of the crime, the defendant:
a. shot a drug dealer who tried to overcharge for cocaine. b. acted on auditory hallucinations of the voice of God commanding, "Kill the children." c. tampered with the brakes on his wife's car after discovering she had an extramarital affair. d. was frightened because of a home robbery the preceding night, assumed a family member was another burglar, and shot him.