Which initial nursing approach makes limit-setting better accepted by clients who are aggressively acting out?
A. Confronting clients with their needs for secondary gains
B. Teaching relaxation techniques
C. Reflecting back to the client empathy about the client's distress
D. Presenting appropriate values that need to be modified
C
Reflecting back to the client empathy about the client's distress promotes a trusting relationship and may prevent the client's anxiety from escalating when limits are set.
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A supervisor is reviewing the documentation of the nurses in the unit. The documentation that most accurately and correctly contains all the required parts for a narrative entry is the entry that reads:
1. "1630 Catheterized using an 8 French catheter, 45 ml clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mother's arms following catheter removal. M. May RN" 2. "1/9/05 2 P.M. g-tube accessed, positive air gurgle over stomach: 5 ml air injected, 10 ml residual stomach contents returned to stomach, Pediasure formula hung on Kangaroo pump infusing at 60 mL/hr for 1 hour. Child grunting intermittently throughout procedure. K. Earnst RN" 3. "4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. F. Luck RN" 4. "Feb. '05 Portacath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gammaglobulins hung and infusing at 30mL/hr. Child smiling and playful throughout the procedure. P. Potter, RN"
A 15-year-old patient is hospitalized after a suicide attempt. The adolescent lives with his mother, stepfather, and several siblings. When performing a family assessment, the nurse must first determine
a. how the family expresses and manages emotion. b. the names and relationships of the patient's family members. c. the communication patterns between the patient and parents. d. the meaning the patient's suicide attempt has for family members.
A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby
Initial therapeutic approach to the mother should be: a. restating what the physician has told her about plastic surgery. b. encouraging her to express her feelings. c. emphasizing the normalcy of her baby and the baby's need for mothering. d. recognizing that negative feelings toward the child continue throughout childhood.
An older patient with mild musculoskeletal pain is being seen by the primary care provider. The nurse anticipates that treatment of this patient's level of discomfort will include:
A) fentanyl B) diazepam C) acetaminophen D) meperidine