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The nurse is assessing a client after an abdominal surgery who speaks a different language. Which nonverbal assessment changes could indicate pain is present? Select all that apply. Confusion Restlessness Poor eye contact Moaning Irritability - Confusion Restlessness Moaning Irritability T...

1. During a therapeutic group, a client talks about personal accomplishments in an effort to gain attention. Which group role, assumed by this client, should the nurse identify? 1. Task role of gatekeeper 2. Individual role of recognition seeker 3. Maintenance role of dominator 4. Task role of ...

Which interventions are helpful when caring for a client with impaired vision? Select all that apply. Suggest the client use soft, diffuse lighting. Advise the client to avoid wearing sunglasses when outdoors. Offer large-print books and reading material. Clean the client's eyeglasses daily. P...

John retired from work last month after 38 years with the same corporation. He's been looking forward to retirement at the age of 65, but is concerned that the days are beginning to wear on him. Physically he does "okay." His hypertension is under control with medications and he runs 2 miles th...

The nurse is evaluating the effectiveness of therapy in a patient with asthma. Which statement made by the patient indicates an effective outcome of the therapy? Select all that apply. A. "I stopped smoking 3 months ago" B. "I keep my pets in a separate room" C. "I can speak in complete sen...

The nurse is caring for a patient who received a large dose of an opioid for pain control 15 minutes ago. Respirations are 10 and shallow. Arrange these actions in the priority order. Deliver naloxone Stimulate the patient Provide a sternal rub Obtain pulse oximetry - 1.) Obtain pulse oximetry ...

The nurse is documenting care of a patient following the APIE method. Which of the following would you expect to see in the nursing note?Select all that apply. 1) Pt able to get dressed and eat in dining room 2)Developed therapeutic relationship w/ pt, stayed w/ pt while ehe ate dinner, encourage...

A patient approaches a nurse with a look of distress and anguish on his face and shares, "Can't you hear him? It's the devil. He's telling me I'm going to hell." What symptom of schizophrenia is this patient experiencing? Delusions of reference Circumstantiality Hallucinations Grandiose ...

A client with irritable bowel syndrome is instructed to begin using a food diary. The client is unclear as to why a food diary is needed. What is the basis of the nurse's explanation? Flare-ups of the disease process are associated with increased caloric intake. Food selection should be based on...

A nurse is assessing pain in a client using the pain scale. The client is crying from pain and is barely able to speak. The client describes his or her pain as a 2 on a scale of 0 to 10. What can the nurse assume? - The client may not understand the pain scale. A nurse notes a history of peripher...

?Which symptoms are common in the initial stage of opioid withdrawal? Select all that apply. Excess tearing Yawning Stomach cramps Muscle aches Perspiration - Yawning Muscle aches Perspiration At the peak of opioid withdrawal, the nurse should anticipate which symptom to occur? Cardiac arre...

A nurse is asked to record the size of the zone of coagulation for a burn victim. Which of the following is appropriate? A) The nurse measures the outer, reddened area of the burn. B) The nurse employs the "Rule of Nines." C) The nurse measures the diameters of the most severely burned area. ...

A client is diagnosed with metabolic syndrome. Which topic should the nurse include in the teaching session for this client? Diabetic ketoacidosis Type 1 diabetes mellitus Type 2 diabetes mellitus Gestational diabetes mellitus - A nurse is teaching about a glycosylated hemoglobin test. Which s...

A patient has been giving a nursing diagnosis of hopelessness. Which of the following actions is appropriate for the planning step? 1)Assess patient for any thoughts of suicide. 2)Interventions selected based on assessment 3)Encourage client to explore and discuss thoughts of hopelessness. 4)Ac...