Hesirn - Study guides, Class notes & Summaries

• A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” the nurse recognizes that the client is using which defense mechanism? a. Denial b. Projection c. Rationalization d. Splitting • A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining...

A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? A. Report the client’s serum lithium level to the HCP. B. Encourage the client to suck on hard candy to relieve the symptoms. C. No action is needed since polydipsia is a common side effect. D. Tell the client that drinking from the faucet is not allo...

A client with depression remains in bed most of the day, and declines activities. Which nursing problem has the greatest priority for this client? A. Loss of interest in diversional activity. B. Social isolation. C. Refusal to address nutritional needs. D. Low self-esteem. The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? a. Lithium. (L...

• The nurse is has just admitted a client with severe depression. From which focusshould the nurse identify a priority nursing diagnosis? A) Nutrition B) Elimination C) Activity D) Safety The correct answer is D: Safety • While explaining an illness to a 10 year-old, what should the nurse keep in mind about thecognitive development at this age? A) They are able to make simple association of ideas B) They are able to think logically in organizing facts C) In...

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? A.Encourage substitution of positive thoughts for negative ones B.Establish trust by providing a calm, safe environment C.Progressively expose the client to larger crowds D.Encourage deep breathing when anxiety escalates in a crowd A male client is admitted to the psychiatric...

While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A. The nurse’ ability to directly observe the client’s nonverbal communication is limited with note taking. B. Taking notes during an interview is a legal obligation of the examining nurse. C. The client’s comfort level is increased when the nurse breaks eye contact to take note to take note. D. The interview process...

• The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN. The correct answer is A: Make certain the child is maintained in correct body alignment. • The nurse is...

1. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruatio...

1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN. The correct answer is A: Make certain the child is maintained in correct body alignment. 2. The nurse is a...

• After an explosion at a factory one of the workers approaches the nurse and says “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness • Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An a...