Explaining that hallucinations are not real would not be an appropriate intervention to address hallucinations in an adolescent client experiencing the manic phase of bipolar disorder. Hallucinations are perceptual experiences that feel real to the individual experiencing them, even though they are not based in reality. Telling the client that hallucinations are not real may invalidate their experiences and can potentially worsen their distress or increase feelings of confusion.
Including the instruction to increase protein in the diet would be appropriate when reinforcing teaching with a client who has a new diagnosis of dumping syndrome following gastric surgery.
For an effective bladder training program to address urinary incontinence resulting from impaired awareness of bladder fullness, the best nursing intervention to include in the plan of care is:
Assist the patient onto the bedside commode every 2 hours.
Bladder training aims to help individuals regain control over their bladder function and improve awareness of bladder fullness. It involves establishing a regular voiding schedule and gradually increasing the time between voids to increase bladder capacity and improve control.
The nursing action that the RN can delegate to an experienced LPN when caring for a patient with a hypertensive crisis receiving sodium nitroprusside (Nipride) is:
"Set up the automatic blood pressure machine to take BP every 15 minutes."
Setting up the automatic blood pressure machine and ensuring that it takes blood pressure measurements at regular intervals can be delegated to an LPN. This task involves technical skills and can be performed by an experienced LPN under appropriate supervision.
The client with acute glomerulonephritis should report the manifestation of pitting edema to the healthcare provider.
Acute glomerulonephritis is an inflammatory condition affecting the glomeruli of the kidneys. It can lead to impaired kidney function and the development of various complications. Pitting edema is a common manifestation of fluid retention and can indicate worsening kidney function or fluid overload.
The priority finding in a newborn receiving phototherapy and with a high bilirubin level is not "sunken fontanels."
Sunken fontanels typically indicate dehydration in infants. However, when managing an infant with high bilirubin levels and undergoing phototherapy, the priority finding would be related to the effectiveness of the treatment and monitoring the bilirubin levels.
The priority nursing intervention for a client admitted with a personality disorder observed engaging in aggressive behavior, such as pulling another client's hair and pushing clients out of their chairs, would not be to remove the client from the room and address the behavior privately.
The appropriate statement by the nurse regarding colon cancer screening for women ranging from 45 to 65 years of age would be:
"Fecal occult blood tests should be done annually beginning at age 50."
Colon cancer screening is an important preventive measure to detect and prevent the development of colon cancer. The recommended age to start colon cancer screening may vary based on guidelines from different organizations. However, most guidelines suggest starting regular screening at age 50 for individuals at average risk.
The finding that the client sits with others in the lounge area conversing about current affairs indicates that the treatment plan has been beneficial for this client with a personality disorder.
Personality disorders often involve difficulties in forming and maintaining relationships, social interactions, and communication. Clients with personality disorders may struggle with interpersonal skills, have intense and unstable emotions, and experience challenges in relating to others.
The nurse should anticipate a prescription for a gastrointestinal x-ray with contrast for a client being admitted with a suspected tumor of the jejunum.
A gastrointestinal x-ray with contrast, also known as a barium swallow or barium meal, is a diagnostic imaging test that involves the use of contrast material (barium) to visualize the digestive tract. It can help identify abnormalities, such as tumors, strictures, or other structural changes in the jejunum or other parts of the gastrointestinal tract.
The nurse should use a Venturi mask to deliver a precise amount of oxygen to the client who has dyspnea and requires continuous oxygen therapy.
A Venturi mask is a type of oxygen delivery device that provides a high-flow and precise oxygen concentration. It is designed to mix a specific amount of oxygen with room air to deliver a precise oxygen concentration to the patient. The mask contains a venturi valve or adapter with different color-coded ports that correspond to specific oxygen flow rates and concentrations.
The nurse should report a blood pressure reading of 89/54 mmHg following epidural placement.
Epidural anesthesia is a common method used for pain relief during labor. However, one potential side effect of epidural anesthesia is a drop in blood pressure, known as hypotension. This occurs because the epidural anesthesia can cause vasodilation, leading to decreased systemic vascular resistance and subsequent lower blood pressure.
The nursing diagnostic of "Risk for other-directed violence" would be of utmost importance for the client described.
Given the client's history of hurling objects at other clients, it indicates a potential risk for violent behavior towards others. Ensuring the safety of both the client and others in the behavioral health unit is a critical priority for the nurse.
