A terminally ill patient has developed delirium since admission to the ICU. Which nursing interventions are indicated?
1. Collaborate with the physician to eliminate any medications that have the side effect of delirium.
2. Collaborate with the physician regarding the administration of haloperidol or ziprasidone.
3. Restrain the patient to prevent injury.
4. Avoid confrontation by "going along" with the patient's hallucinations.
5. Use objects like the television or newspapers to help maintain patient orientation.
1, 2, 5
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Which interventions should the nurse implement for a newborn with a subgaleal hemorrhage? (Select all that apply.)
a. Monitor bilirubin levels. b. Monitor hematocrit levels. c. Prepare the newborn for skull radiography. d. Monitor the newborn's level of consciousness. e. Place a warm compress on the affected area.
The nurse is collecting data on a 9-year-old child suspected of having a brain tumor. Which of the following questions would the nurse ask to elicit data related to the classic symptoms of a brain tumor?
1. "Do you have trouble seeing?" 2. "Do you feel tired all the time?" 3. "Do you have headaches late in the day?" 4. "Do you feel sick to your stomach, and do you throw up in the morning?"
A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse pull the pinna for this age of child?
a. Up and back b. Down and back c. Straight back d. Straight up
A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion?
a. Cecum, ascending, transverse, descending, sigmoid, and rectum b. Ascending, transverse, descending, sigmoid, rectum, and cecum c. Cecum, sigmoid, ascending, transverse, descending, and rectum d. Ascending, transverse, descending, rectum, sigmoid, and cecum