Which assessment data indicates to the nurse that a client is undergoing alcohol withdrawal?
A) Suicidal ideation and increased appetite
B) Lacrimation, rhinorrhea, and piloerection
C) Tremors, tachycardia, and sweating
D) Belligerence and assaultiveness
Question 2
A client has been feeling increasingly overwhelmed by work and school responsibilities. This evening, his wife found him in the garage assembling a noose. When she questioned him, he began to cry.
She immediately brought him to the emergency department. To assess suicide potential, which nursing question is inappropriate?
A) Have you thought about harming yourself?
B) Why do you want to harm yourself?
C) How have you planned to harm yourself?
D) Do you have the means with which to carry out the plan?
Patient teaching: neck assessment
Nursing history for breast assessment
Measuring the client’s weight with a standard platform scale
Testing client’s ability to identify dull sensation
Testing patellar reflex, client in a supine position
Client’s view with visual field loss