Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?
A. Risk for infection related to stasis of alveolar secretions
B. Impaired skin integrity related to pressure
C. Activity intolerance related to pump failure
D. Constipation related to immobility
Ans: C. Activity intolerance related to pump failure
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A patient and his family have been exposed to probable anthrax spores through contaminated postal contents within the past 8 hours. Upon arrival at the emergency department, all members of the family are anxious and say they are afraid of dying
The best nursing response is based on what rationale? A) There is no treatment for anthrax exposure and their fears are realistic. B) A vaccine given in the first 3 days after exposure will stop the disease. C) Antibiotic therapy is very effective for cutaneous anthrax. D) A toxicology screen is necessary to determine whether there really was an exposure.
The nurse working in home care is about to knock on the client's door when shouting is heard through the door
The client and spouse are shouting at each other, and the nurse hears the spouse tell the client to put the gun down before someone gets hurt. The nurse's priority action is to: 1. Enter the apartment and help the spouse calm the client. 2. Call the police and put some distance between the nurse and the apartment. 3. Call the police and wait for them by the door of the apartment. 4. Go to the next client to be seen and notify the agency why this client wasn't visited.
The client is having a Weber test. During a Weber test, where should the tuning fork be placed?
A) On the mastoid process behind the ear B) In the midline of the client's skull or in the center of the forehead C) Near the external meatus of each ear D) Under the bridge of the nose
With an intact oculocephalic reflex, the
a. patient's eyes move in the same direction the head is turned. b. patient's eyes move in the opposite direction to the movement of the patient's head. c. patient's eyes remain midline. d. doll's eye reflex is absent.