General interventions to minimize anxiety in the hospitalized client include providing information, social support, control over choices related to care, and acknowledging the client’s feelings. Being far from the nursing station is unlikely to reduce anxiety for this client. Limiting visitors reduces social support, and leaving the door open with hallway lights on may keep the client oriented, but may interfere with sleep and increase anxiety.
Clients who are withdrawn may be immobile and mute, and require consistent, repeated approaches. Intervention includes establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The client is not left alone. Asking direct questions to this client is not therapeutic.
PTSD is precipitated by events that are overwhelming, unpredictable, and sometimes life threatening. Typical symptoms of PTSD include difficulty concentrating, sleep disturbances, intrusive recollections of the traumatic event, hypervigilance, and anxiety.
Adolescents who withdraw from peers into isolation struggle with developing identity.
Signs of depression include withdrawal, lack of interest, crying, anorexia, and apathy. Insomnia may be a sign of anxiety or fear. Ignoring symptoms and activity restrictions are signs of denial. Apprehension is a sign of anxiety.
Distancing is an unwillingness or inability to discuss events. Self-control is demonstrated by stoicism and hiding feelings. Problem solving involves making plans and verbalizing what will be done. Accepting responsibility places the responsibility for a situation on one’s self.
The first step in client teaching is establishing what the client already knows. This allows the nurse to not only correct any misinformation but also to determine the starting point for teaching and to implement the education at the client’s level.
The signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours. Early signs include anxiety, anorexia, insomnia, tremor, irritability, an elevation in pulse and blood pressure, nausea, vomiting, and poorly formed hallucinations or illusions.
The monotony of immobilization can lead to sluggish intellectual and psychomotor responses. Regressive behaviors are not uncommon in immobilized children and usually do not require professional intervention.
Presbycusis occurs as part of the aging process and is a progressive sensorineural hearing loss. Some clients may not adapt well to the impairment, denying its presence. Others withdraw from social interactions and contact with others, embarrassed by the problem and the need to wear a hearing aid. Clients show adequate adaptation by obtaining and regularly using a hearing aid.
Bald spots on the scalp are most likely associated with physical abuse. The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may be indicative of physical neglect.
The client is at risk for developing gestational diabetes with each pregnancy. The client also has an increased risk of developing diabetes mellitus and needs to comply with follow-up assessments. She also needs to be taught techniques to lower her risk for developing diabetes mellitus, such as weight control. The diagnosis of gestational diabetes mellitus indicates that this client has an increased risk for developing diabetes mellitus; however, with proper care it may not develop.
Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16 year old. The nurse needs to further assess this statement immediately to find out why the client feels the need to exercise this much to maintain her figure. Although it’s unfortunate that her best friend had this disease, this is not considered a major threat to this client’s physical well-being. A weight that exceeds 15% below the ideal weight is significant with anorexia nervosa. It is not considered abnormal to check weight every day. Many clients with anorexia nervosa check their wei
An inactive older person may become disoriented due to lack of sensory stimulation. The most appropriate nursing intervention would be to frequently reorient the client and to place objects such as a clock and a calendar in the client’s room to maintain orientation. The family can assist with orientation of the client, but it is not appropriate to ask the family to stay with the client. It is not the within the scope of nursing practice to prescribe laboratory studies. Restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before application of restraints.
A client experiencing paranoia is distrustful and suspicious of others. The health care team needs to establish rapport and trust with the client. Laughing or whispering in front of the client would increase the client’s paranoia.
It is possible to have a sexual relationship after a spinal cord injury, but it is different than what the client experienced before the injury. Males may experience reflex erections, although they may not ejaculate. Females can have adductor spasm. Sexual counseling may help the client adapt to changes in sexuality after spinal cord injury.
Signs and symptoms of a brain tumor vary depending on location and may easily be attributed to another cause. Symptoms include headache, vomiting, visual disturbances, and change in intellectual abilities or personality. Seizures occur in some clients. These symptoms can be easily attributed to other causes.
Rest is an essential component of bone healing. Nurses can help clients understand the importance of rest and find ways to balance work demands to promote healing. Nurses cannot demand these changes but need to encourage clients to choose them. It may be stress relieving to do work; however, in the immediate post-cast period, it may not be therapeutic. Stress should be kept at a minimum to promote bone healing. Setting limits on a client’s behavior is not a mandated nursing role.
Clients receiving TPN are at risk for development of essential fatty acid deficiency.
Clients who are on narcotics often have well-founded fears about addiction, even in the face of pain. The nurse has a responsibility to provide correct information about the likelihood of addiction while still maintaining adequate pain control. Addiction is rare for individuals who are taking medication to relieve pain.
CPT is an intervention to assist in mobilizing and clearing secretions and enhance more effective breathing
Depression is a common problem related to clients who have long-term and debilitating illness.
Accurate information reduces fear, strengthens the nurse-client relationship, and assists the client to deal realistically with the situation.
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