Exam 3 Transitions

PTSD- A client is admitted with recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of PTSD. SATA

I keep reliving the robbery I see his face everywhere I go I might have died over a few dollars in my pocket

Therapeutic communication (1) - The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is most helpful response by the nurse?"

What do you find difficult about this situation?

Force

1 person achieves his or her goals at the expense of other person

Accommodation

1 person puts aside his or her goals to satisfy the other desires

Accurate Nursing Documentation maybe?

A client with tentatively diagnosed with Graves disease. Which of the following noted on initial nursing assessment requires quick intervention by the nurse? - the appearance of eyeballs that appear to "pop" out of clients eye socket

Conflict resolution skills (maybe??)

Victims of physical abuse Are you in danger now? Elder abuse most risk is elder women with dementia When couples fight its normal but how do you guys deal with conflict or fight?

DM education question A 67 year old client with non-insulin-dependent diabetes should be instructed to contact the outpatient clinic immediately if the following are present?

An open reddened wound on the heel

Dietary instructions for a patient who had cholecystectomy?

Avoid gassy foods eat small, low fat foods beans, cabbage, cauliflower, broccoli take fat soluable vitamins or bile salts as rx

Alcohol withdrawal (protocol)

Ask when was your last drink What type of alcohol how much for how long and when last consumed

post laryngectomy care

Avoid shower Wear high collar shirt Keep home humidified Avoid people with infection (crowds) *increase fluids *minimize talking

collaboration

Both people actively try to find solutions that will satisfy them both

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? SATA

Communicate expected behaviors to client Assist the client in identifying setting limits on personal behaviors Follow through about the consequences of behaviors in a nonpunitive manner Have client state consequences for behaving in the ways that are viewed as unacceptable Intervention for a client experiencing mania: Provide frequent breaks

Hep A what to avoid/intervention

Fecal Oral wash hands No seafood Clean toilets

Caring for the hospice patient

Focuses on caring interventions and symptom management rather than cure for diseases or conditions that no longer respond to treatment - Pain and symptoms are controlled (dying client should be pain free and as comfortable as possible) - Provides support and care for clients of any age in the last phases of incurable diseases so that they might live as fully and as comfortably as possible

`Expected symptoms/labs for a child with CRF

GFR less than or equal to 60 ml/min for 3 months or longer Increase BUN and creatinine Oliguria hyperkalemia hypermagnesemia Hypertension Gi bleeding; anemia

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions?

Information regarding shelters

A nurse is completing a preoperative teaching for a client who is to undergo an arthoscopy to repair a shoulder injury. Which of the following statements should the nurse include SATA

Inspect your incision daily for indications of infection Apply ice packs to area for first 24 hrs Perform isometric exercises

Education for new HTN

Keep a diary of BP readings Intruct patient to bake roast or boil food Avoid OTCs Decrease sodium 1-2g Exercise 5 days a week for 30 mins

Fire Safety

Keep open spaces free of clutter Clearly mark fire exits Know the locations of all fire alarms, exits and extinguishers Never use elevator Know evacuation plan Turn off oxygen and appliances in the vicinity of the fire

Alcohol withdrawal interventions

Monitor VS Provide safe environment (seizure precautions) Address hallucinations therapeutically decrease stimulation Provide reality orientation as appropriate

Obtaining consent for a patient who is not AAO

Obtain a telephone consent from a family member following agency policy

How to use a fire extinguisher (PASS)

P - *Pull* the pin A - *Aim* at base of fire S - *Squeeze* handle S - *Sweep* extinguisher from side to side.

Reye's syndrome Patient teaching? Care Plan? Further teaching?

Parents watch TV in the child's room with the volume up. - Provide a quiet atmosphere with dimming lighting

Which action will the nurse include in the plan of care for a patient who is being admitted with Cdiff

Place the client in private room for contact precautions

Caring for a hip fracture before surgery

Preoperative treatment includes balanced suspension or skin traction to relieve muscle spasms and reduce pain

Prevention of Hep C

Prevent Needle stick

Priority actions for a fire RACE

Rescue and remove clients and staff who are in immediate danger activate fire alarm Confine the fire Extinguish the fire

Hyperthyroidism and goiter additional teaching if performed by new RN

Rn checks the intial BP in one arm Rn palpates the neck to assess thyroid size rn orders saline eyedrops to lubricate the client bulging eyes RN offers warm blankets for the client cold feet

Conflict resolution skills

Successful resolution to conflict begins to occur when people are aware of their own and other feelings and emotions - Use I rather than you messages to avoid defensive responses Dont make these personal

antipsychotic medications moving mouth, protruding tongue, and grimaces as watching TV.

Tardive dyskinesia

Chronic Anxiety Identify triggers? Which goal would be most/appropriate to be included in the plan of care requiring evaluation?

The patient is able to identify triggers that produce anxiety

The nurse and a student nurse are discussing the specific points about infants born to HBsAg positive mothers. Which of these comments by the student indicates a need for clarfication of info?

The third dose should be given at least 16 weeks from the second dose

conflict resolution styles

avoidance, accommodation, force, compromise, collaboration

compromise

both people give up something to get partial goal attainment

dissociative identity disorder When working with a patient with dissociative amnesia, the nurse should begin by

identifying and supporting the patient strengths *Provide trusting relationships *Avoid challenges

avoidance-avoidance conflict

uses passive behaviors and withdraws