The nurse has just completed an interview and physical examination of a newly admitted client. What sources of information should this nurse use in formulating expected outcomes for the client?
A. Identified nursing diagnoses and collaborative problems
B. The goals for the client as set by family members
C. The medical history and laboratory test results
D. Client goals as set by the nursing staff
A
After establishing priorities, the client and nurse reach a mutual decision regarding expected outcomes based on identified nursing diagnoses and collaborative problems.
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A woman who travels extensively for her job has been prescribed triazolam (Halcion) as a sleep aide. During patient teaching, what information should the nurse prioritize?
A) "To avoid becoming dependent on this drug, you should only take it every other night." B) "Having one to two alcoholic drinks each evening can make Halcion more effective." C) "You need to plan your bedtime carefully, because you should take this drug 1 to 2 hours before you want to sleep." D) "If you stop taking this drug suddenly, you might find that your insomnia is worse than ever."
The National Patient Safety Goals established by the Joint Commission focus on:
a. regulatory standards c. employee safety b. preparation for accreditation d. patient safety
A patient reports seeing a "frightening" face on the wall of the dayroom. A nurse attempts to calm her by providing an explanation for the flawed perception of what she saw. The nurse would implement this strategy by stating:
a. "Let's see if anyone else has seen those frightening faces on the walls of the dayroom.". b. "The shadows of the tree outside the window make strange shapes on the dayroom walls.". c. "Have you ever seen frightening faces like that on the dayroom walls before today?" d. "Did someone in the dayroom tell you there were frightening faces on the walls?"
To decrease the pain associated with an episiotomy immediately after birth, which action by the nurse would be most appropriate?
A) Offer warm blankets. B) Encourage the woman to void. C) Apply an ice pack to the site. D) Offer a warm sitz bath.