A patient underwent surgery 3 days ago for colorectal cancer. The patient's critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care
The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed?
1) Postpone the teaching session until the patient is more receptive.
2) Follow the critical pathway for patient teaching
3) Administer a prescribed antidepressant and notify the physician.
4) Explain to the patient the importance of skin care around the ostomy site.
ANS: 1
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When should the nurse assess pain?
a. Whenever a full set of vital signs is taken b. During the admission interview c. Every 4 hours for the first 2 days after surgery d. Only when the patient reports pain
To provide adequate postpartum care, the nurse should be aware that postpartum depres-sion (PPD) without psychotic features:
a. Means that the woman is experiencing the baby blues. In addition she has a visit with a counselor or psychologist. b. Is more common among older, Caucasian women because they have higher ex-pectations. c. Is distinguished by irritability, severe anxiety, and panic attacks. d. Will disappear on its own without outside help.
A patient has just received information regarding the goals of a partial-hospitalization program. Which statement best indicates patient understanding?
a. "I think that the partial-hospitalization program will provide a good interim rest for me.". b. "The partial-hospitalization program will be a good support to me as I adjust to the stress of being back home.". c. "I know that partial hospitalization seems like a small step, but it will prevent readmission to the hospital.". d. "I'm looking forward to the partial-hospitalization program, because I can gather my thoughts there and think about what I want to do.".
A supervisor is reviewing the documentation of the nurses in the unit. Which client documentation is the most accurate and contains all the required part for a narrative entry?
1. "2/2/05 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 pm NG tube placement confirmed and irrigated with 30 ml sterile water. Suction set at low, intermittent. Oxygen via nasal canal at 2 L/min. Nares patent, pink, and nonirritated. 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. Respirations regular and even throughout the procedure. F. Luck RN" 4. "Feb. '05 Port-A-Cath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gamma globins hung and infusing at 30cc/hr. Child smiling and playful throughout the procedure. P. Potter, RN"