The data element obtained during nursing assessment that supports the presence of a fugue state is
that the client states he
a. cannot recall why he is living in his present location.
b. feels as if he is living in a fuzzy dream state.
c. feels very anxious about his problems.
d. feels that different parts of him are at war.
ANS: A
The client in a fugue state frequently relocates and assumes a new identity while not recalling his
previous identity or where he lived in the past. Option B is more consistent with depersonalization
disorder. Option C is consistent with generalized anxiety disorder. Option D is consistent with
feelings experienced with dissociative identity disorder.
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The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff?
a. Prevent regurgitation after meals b. Hold the trachea open until it is completely healed c. Dilate the tracheal opening for passage of secretions d. Prevent aspiration when eating
In the earliest primitive societies, people believed that mental illness was the result of
1. an imbalance of humors. 2. demons and evil forces. 3. microbes and bacteria. 4. witches and magicians.
Ethylene glycol has a specific gravity of 1.125. What is the mass of 0.5 L ethylene glycol?
A. 0.5625 g B. 0.4444 g C. 562.5 g D. 2.25 g
On one of the first days working alone, the novice nurse must provide teaching on tracheotomy care to the client as well as the client's spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to:
a) ASk the nurse mentor to assist with the teaching after reviewing the procedure b) Read the policy and procedure manual before the teaching session c) Do the best the nurse can by remembering what was taught in nursing school d) ASk for a different assignment until the nurse feels comfortable with this one