fever of 100°F to 103°F increased appetite, especially for sweets excessive sleeping of 14 hours or more daily onset of delirium 12 to 24 hours after the last drink onset of delirium 48 to 72 hours after the last drink disorientation and fluctuating levels of consciousness
The nurse is caring for a client who is a victim of domestic violence. Which of the following would the nurse expect to find in the client’s social history?
The client is under 30 years old. The client is active in a local charity. The client has a history of child abuse. The client has been in past abusive relationships. The client is employed as a college professor.
A nurse has admitted a client to the mental health unit following an attempted suicide. The client also attempted suicide four months earlier. Which is the best way to ensure client safety?
give the client a task to do, such as folding towels, to distract him assign a staff member to remain with the client one-on-one at all times obtain an order for chemical and physical restraints to be used as needed keep the client in the day room around other clients who can help watch the…
The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client?
help the client bathe and change into fresh clothing before the examination begins preserve any evidence, including clothing, and take photographs of injuries as appropriate assure the client that surviving the assault is most important, and she did what was needed to stay alive take the client to a quiet, private room for assessment to…
The nurse is caring for a client who is taking tricyclic antidepressants. Which statement by the client indicates that the medication is working properly?
“I haven’t felt like going to work this week.” “I’ve joined a bridge club in my neighborhood.” “I sleep 12 hours a night and take a nap during the day.” “I have felt my heart racing since I started the medicine.”
A nurse on the mental health unit is preparing a presentation on suicide for a group of student nurses. Which information would be included in this presentation?
Chronic pain or serious, disabling illness has little to no effect on suicide risk. Hispanic Americans attempt suicide at a greater rate than whites or African Americans. Suicide risk declines sharply once antidepressant medication has been taken for a few weeks. White males over the age of 80 are at the greatest risk among all…
The nurse is caring for a client diagnosed with bipolar disorder. During the morning assessment, the client tells the nurse that she hears people in the room behind her bed talking about her. Which response by the nurse best reflects therapeutic communication?
“What do you hear them saying?” “I will see if we can move you to another room.” “I will notify your doctor in case he wants to change your medications.” “I understand that the voices seem real to you, but I don’t see or hear anyone else in here.”
The nurse is caring for a client for whom English is a second or other language and who is very reluctant to disclose personal information. Which statement reflects an understanding of culturally or socially competent care for this specific client?
Making direct eye contact with the client may be viewed as disrespectful. Care and activities should be scheduled around designated prayer times whenever possible. The patient may be undocumented, fearful of disclosing his or her status, and therefore cautious in institutional settings. The patient may not be well educated.
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Which is the priority nursing action while caring for this client during the treatment?
monitor the airway and be prepared to provide suction if needed continuously observe vital signs and cardiac function on the monitor provide support and safe positioning to the client’s arms and legs during the seizure record the type, frequency, duration, and amount of movement induced by the seizure
A 79-year-old client with moderate dementia and limited mobility is being cared for at home by her son who lives with her. She has been receiving home health for care of a nonhealing diabetic foot ulcer. The home health nurse encourages the son to bring his mother to the ED for more aggressive treatment in an in-patient setting. The son responds that he cannot afford to pay for the medical bills and prefers to care for her at home. The nurse then notices a stage 2 decubitus ulcer on the client’s sacrum. The son claims to have his sister come every day and assist with bathing and turning in the bed. Which type of violence is the son guilty of?
physical neglect physical violence emotional violence economic exploitation