The psychiatric examination includes a psychiatric history and a mental status assessment. When conducting the mental status assessment, the nurse: Standard Text: Select all that apply
1. Includes observations.
2. Limits the assessment to verbal responses.
3. Provides the client with a form to complete.
4. May or may not follow a strict sequence.
5. Uses a group format.
1,4
Rationale: Includes observations. Several components of the assessment require observational skills of the nurse.
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The nurse is working with a family who has recently immigrated to this country. The nurse has recently studied Purnell's Model for Cultural Competence (2002), and wants to respond to the family in a culturally acceptable manner
The most appropriate assessment question(s) would be: 1. "In what places have you lived?" and "What do you miss about your native land?" 2. "When I discuss your child's problem with you, how close to you should I stand?" 3. "What does eye contact indicate?" and "When do you want me to make eye contact?" 4. "What is the school system like in your native land?"
The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of her three meals and had another 150 mL with her medications
The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume in order to stay within the prescribed fluid restriction? a. 100 mL b. 150 mL c. 250 mL d. 300 mL
A male patient who has had spinal anesthesia is under a physician's order to lie flat postoperatively. When the patient asks to go to the bathroom, the nurse encourages him to comply with the physician's order
The rationale for complying with this order is to prevent the onset of: A) Hypotension B) Respiratory depression C) A headache D) Pain at the lumbar injection site
A client with pneumonia is weak and cannot cough effectively. After suctioning the client, the nurse records the evaluation data in the chart. Which statement is the best indicator of positive effects of the suctioning procedure?
1. "Thick, yellow sputum returned through suctioning." 2. "Color good, pulse 90, respirations 20, BP 140/88." 3. "Lungs clear throughout upon auscultation." 4. "The client reports feeling better."