A nurse is monitoring a patient with a brain injury for signs of increased cranial pressure. Which of the following accurately states the symptom of this condition?
A) Hyperactive reflexes
B) Equal pupils
C) Widening of pulse pressure
D) Increased papillary response to light
C
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A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?
a. Immobilize the left arm. b. Assess the client's distal pulse. c. Monitor for signs of infection. d. Administer prescribed steroids.
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg
Which question should the nurse ask first? a. "Did you take any acetaminophen (Tylenol) today?" b. "Have you been consistently taking your medications?" c. "Have there been any recent stressful events in your life?" d. "Have you recently taken any antihistamine medications?"
Spirituality plays a role in the care of a patient. A nurse should be aware that spirituality consists of:
1. Individualized definitions of God. 2. Individualized concepts of how the human race began. 3. Individualized concepts of what others should believe. 4. Individualized concepts of a greater being who affects daily life. 5. Individualized concepts of eternity.
The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. The most appropriate nursing action is to:
a. Ignore the sound. b. Ask him to reverse the hearing aids in his ears. c. Suggest that he reinsert the hearing aid. d. Suggest that he raise the volume of the hearing aid.