What is the priority need for a patient diagnosed with severe, late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering ● Maintenance of nutrition and hydration A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse’s comments and asks, “What do you mean? What are they going to do?” Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient’s level of anxiety? a. Mild b. Moderate c. Severe d. Panic A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for a. coma. b. seizures. c. hypotonia. d. respiratory depression. While performing an assessment, the nurse says to a patient, “While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now?” The purpose of this question is to a. identifies areas of sexual dysfunction for treatment. b. determines possible homosexual urges. c. introduces the topic of masturbation. d. identifies sexual misinformation. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depressive disorder. Which comment by the patient indicates teaching about the procedure was effective? a. “They will put me to sleep during the procedure, so I won’t know what is happening.” b. “I might be a little dizzy or have a mild headache after each procedure.” c. “I will be unable to care for my children for about 2 months. d. “I will avoid eating foods that contain tyramine.” A patient experiences a sudden episode of severe anxiety. Of these medications in the patient’s medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone b. lorazepam c. amitriptyline d. desipramine A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a. An interview room furnished with a desk and two chairs b. A small, empty storage room with no windows or furniture c. A room with an examining table, instrument cabinets, desk, and chair d. The nurse’s office, furnished with chairs, files, magazines, and bookcases In assessing the patient for sleep disorder, the nurse asks how long it usually takes to fall asleep at night. The nurse is asking about the patient: a. sleep latency. b. sleep efficiency. c. sleep continuity. d. sleep architecture A patient diagnosed with major depressive disorder says, “No one cares about me anymore. I’m not worth anything.” Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. “You look nice this morning.” b. “You’re wearing a new shirt.” c. “I like the shirt you are wearing.” d. “You must be feeling better today.” has been hospitalized for an acute manic episode. On admission the nurse suspects lithium toxicity. What assessment findings would indicate the nurse’s suspicion as correct? a. Shortness of breath, gastrointestinal distress, chronic cough b. Ataxia, severe hypotension, large volume of dilute urine c. Gastrointestinal distress, thirst, nystagmus d. Electroencephalographic changes, chest pain, dizzine has been hospitalized for an acute manic episode. On admission the nurse suspects lithium toxicity. What assessment findings would indicate the nurse’s suspicion as correct? a. Shortness of breath, gastrointestinal distress, chronic cough b. Ataxia, severe hypotension, large volume of dilute urine c. Gastrointestinal distress, thirst, nystagmus d. Electroencephalographic changes, chest pain, dizzine A person was directing traffic on a busy street, rapidly shouting, “To work, you jerk, for perks” and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient’s plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making