If a pregnant teenager presents with all the complaints below, the nurse recognizes that the one that could signal danger is:
a. painful hemorrhoids.
b. linea nigra.
c. visual disturbances.
d. low back pain.
C
Visual disturbances may be an indicator of increased blood pressure and retained fluids. These are indicators of eclampsia.
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The nurse is preparing to suction a patient with an endotracheal tube. What would be the nurse's first step in the suctioning process?
A) Explain the procedure to the patient before beginning and offer reassurance during suctioning. B) Turn on suction source at or below 120 mm Hg. C) Assess the patient's lung sounds and SaO2 via pulse oximeter. D) Perform hand hygiene, then put on nonsterile gloves, goggles, gown, and mask.
A client being treated for depression with a selective serotonin reuptake inhibitor (SSRI) becomes agitated and diaphoretic and complains of muscle spasms and tremors
The client's sister confides to the nurse that her sister has been taking Saint John's wort daily for the last 6 months. Which action should be taken by the nurse? 1. Ask the client to give the Saint John's wort tablets to the staff. 2. Discuss the dangers of taking over-the-counter herbal preparations with the client. 3. Withhold any scheduled doses of the SSRI and notify the physician. 4. Have the laboratory draw blood work for a serotonin level.
The patient's husband is terrified by the prospect of removing life-sustaining treatments from the patient. He asks why anyone would do that. The nurse explains,
a. "It is to save you money so you won't have such a large financial burden." b. "It will preserve limited resources for the hospital so other patients may benefit from them." c. "It is to discontinue treatments that are not helping your wife and may be very uncomfortable for her." d. "We have done all we can for your wife and any more treatment would be futile."
An older client was admitted to hospice owing to impending death in approximately 6 weeks. After 2 months, the family remains at the bedside but is becoming increasingly impatient and irritable. What is the best nursing intervention?
a. Ask the family to leave and not return un-til they are calmer. b. Sit with the family and listen to their con-cerns and fears. c. Tell the family members not to worry, the client will die soon. d. Consult the chaplain to come and pray with the client's family.