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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)Accept the patient's feelings in a non-judgmental manner. - 2 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?...

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 statement indicates the need for further teaching? "A glycosylated hemoglobin test should be done after 8 hours of fasting." "Physical activity and stress do not alter the results of a glycosylat...

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. D) The nurse records the size of the skin graft. - C A nurse is caring for a patient who has suffered a thermal burn and is now receiving hospitalized care. Which of the following post-burn complica...

?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 arrest Delusions Mania Violent kicking motions - Violent kicking motions Clay asks his brother to get him more oxycodone and he refuses saying "Clay, you need to get help." Clay has a conversation ...

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 peripheral neuropathy in the medical record of a client. What should the nurse include in the assessment of this client? Select all that apply. 1.Deep diffuse pain 2.Numbness of the feet 3.Cramping and ac...

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 following a low-sodium, low-fat diet. Excess fluid intake can lead to exacerbations of the disease. Certain foods can act as triggers and cause flare-ups of the disease. - Certain foods can act as ...

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 delusions - Hallucinations Schizophrenia has four phases. Which of the following accurately depicts a particular phase? Select all that apply. The patient has significant deterioration with depress...

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A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply 1. Diazepam (Valium) 2. Alprazolam (Xanax) 3...

- white blood cells, 4500 to 11,000 cells/mm3; thyroid-stimulating hormone, 0.2 to 5.4 microunits/mL; magnesium, 1.6 to 2.6 mg/dL; calcium, 8.6 to 10.0 mg/dL; blood urea nitrogen, 5 to 20 mg/dL; and serum creatinine, 0.6 to 1.3 mg/dL. A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by - Removing any toy with bright blinking lights Keeping the sides rails of the child's bed padded Turning the inf...

Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction. - A nurse is assessing a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply) a. Shortness of breath b. Abdominal bloat...

A health care provider decided that the emotional distress of an older adult patient warrants the use of risperidone (Risperdal). Which interventions should the nurse add to the patients plan of care? Select all that apply. a. Monitor for signs and symptoms of diabetes. b. Use disposable briefs for incontinence. c. Monitor for cerebrovascular changes. d. Implement a tyramine-free diet. e. Monitor for dehydration. - AC A nurse assesses a patient suspected to have somatic system disorder. ...

1. Which interventions would be appropriate for a faith community nurse who bases care on the CIRCLE Model of Spiritual Care? (Select all that apply.) a. Giving a mini sermon based on the specific client problem b. Listening and showing respect without any actual intervention c. Suggesting to the client what would be an appropriate response to the situation d. Showing love and empathy toward the client and the situation e. Calling the client by name during the conversation f. Allowing tim...

A child and his mother are being sent home after diagnosis of a parasite infection. What does the nurse teach regarding use of anthelmintic medications? SATA 1. take daily baths, not showers 2. change sheets, towels, bedclothes weekly 3. wash hands before eating and after using the bathroom 4. drowsiness may occur 5. take showers, not baths - Ans: 3,4,5 1. do not take baths 2. would change sheets, towels, and bedclothes daily, along with underwear A nurse is assessing a patient who is t...

A nurse has completed an education session on self administration of insulin injections. Which statements describe successful learning in the affective domain? A. I am feeling more confident about insulin self injection B. It is essential to check my blood sugar before I take the insulin C. Insulin works to lower my blood sugar levels D. The patient measures the correct amount of insulin in the syringe for injection E. The patient self injects the insulin using the correct technique - A B...

4. Which of the following sequence is the correct one for replicating DNA? Not all the steps are included. I. RNA Primers anneal to the DNA template II. ssDNA binding proteins bind to stabilize single strand DNA after helicase unwinds it. III. RNA primers are removed and new DNA strand is made by DNA polymerase IIV. DNA ligase connects the DNA fragments V. Complementary copy of DNA is made by DNA polymerase III A) I, II, III, IV, V B) II, III, IV, I, V C) V, I, III, II, IV D) II, I, V, ...

1. A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental st...

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client? O The client will need cuing only. O The client will need safety precautions. c. The client will need near-total care. O The client will be discharged home. - c. . A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care prov...

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+1 slight pitting edema - 2mm depression +2 increased pitting edema - 4mm depression +3 deeper pitting edema - 6mm; obvious edema of extremity +4 severe pitting edema - 8mm depression, extremity appears very edematous 0/5 strength - total paralysis 1/5 strength - muscle contraction is noted but no movement occurs 2/5 strength - some movement but insufficient to counteract gravity, cannot perform ROM against gravity 3/5 strength - contract your muscle and move your body part through its f...