The nurse enters the client's room and finds the client anxiously pacing the floor. The client begins shouting at the nurse, "Get out of my room!" The best intervention by the nurse would be to:
A) Approach the client and ask, "What's wrong?"
B) Call for help and say, "Calm down."
C) Say, "I'm leaving now, but I'll be back."
D) Stand at the doorway and say, "You seem upset."
D
Feedback: Staying with the client while allowing personal space is an important and safe intervention; this therapeutic communication technique is designed to get the client to communicate feelings.
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The client is a functional, contributing member of his community and society. He is flexible and willing to change. His behavior is defined as
1. delusional. 2. mentally healthy. 3. mentally deficient. 4. mentally handicapped.
The nurse notes the following rhythm on a client's telemetry monitor. How does the nurse interpret these findings?
a. Ventricular tachycardia b. Second-degree heart block c. Supraventricular tachycardia d. Premature ventricular contractions
The perinatal nurse is aware that if a respiratory rate of 68 breaths per minute is noted in the newborn, the appropriate nursing actions would include:
Select all answers that apply. A) withholding the feeding. B) continuing assessment of the infant's respiratory rate and color. C) notifying the physician of additional signs or symptoms of respiratory distress. D) documenting the infant's chest measurement.
A patient with myasthenia gravis has been on cholinesterase inhibitor therapy. The patient reports on occasion that she has some difficulty swallowing and periods of fatigue
The patient asks, "What can be done to remedy this?" The nurse's best response would be a. "You are already on a high dosage of the drug. You will have to cope with these symptoms." b. "This could mean that the dosage is too high and you should skip every other dose." c. "Let's discuss some strategies to help you learn to self-adjust the dose in response to your symptoms." d. "You are developing tolerance to the drug and will need to change to a different class of agents."