Which question is most important to ask a patient who is prescribed phenytoin (Dilantin) before?
a. "Do you drink coffee or other caffeinated beverages?"
b. "Have you ever had high blood pressure?"
c. "How many seizures do you have daily?"
d. "What other drugs do you take daily?"
ANS: D
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The nurse is preparing to palpate the rectum and should use which of these techniques? The nurse should:
a. Flex the finger, and slowly insert it toward the umbilicus. b. First instruct the patient that this procedure will be painful. c. Insert an extended index finger at a right angle to the anus. d. Place the finger directly into the anus to overcome the tight sphincter.
You have received oncoming report. Using concepts of Maslow and Watson for priority setting, which client would you assess first?
1. A diabetic patient with a newly diagnosed foot ulcer 2. A patient who is 3-days postoperative following abdominal surgery with no bowel sounds 3. An asthmatic pediatric patient with expiratory wheezing 4. A cardiac client who had chest pain relieved after the third nitroglycerin 1 hour ago.
Sally is an experienced nurse on the unit and is very experienced with ICP monitoring. She is assigned David, a patient who has been admitted with a severe head injury. In communicating with Sally, you would:
a. Provide a detailed explanation of what she needs to do with ICP monitoring. b. Tell her when she needs to provide an update about David's status. c. Ask her to tell you what she knows about ICP monitoring and share expectations about reporting. d. Advise her that you are available if she needs you.
After hospital discharge, what is the priority intervention for a patient with bipolar disorder, who is taking antimanic medication, and for the patient's family?
a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation