A patient presents to the emergency department complaining of headache. Which is the priority question when assessing this patient's symptoms?
1) "Have you been diagnosed with temporomandibular joint (TMJ) syndrome?"
2) "Have you had any recent trauma or injury?"
3) "How often do you experience migraines?"
4) "Have you recently experienced any neck strain?"
ANS: 2
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Which group leader activity should a nurse identify as being most effective in the final, or termination, phase of group development?
1. The group leader establishes the rules that will govern the group after discharge. 2. The group leader encourages members to rely on each other for problem solving. 3. The group leader presents and discusses the concept of group termination. 4. The group leader helps the members to process feelings of loss.
A client in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the client
Which priority intervention should be done by the nurse to help evaluate clinical response to treatment? a. Obtain a pain scale response from the client based on a 0 to 10 scale. b. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. c. Document intake and output on the electronic health record (EHR). d. Increase the flow rate of prescribed parenteral fluid to maintain hydration.
For a client who had a transsphenoidal resection of a pituitary tumor, the nurse plans to
a. assess the "mustache" dressing for drainage. b. do minimal mouth care for the first 2 days. c. encourage the use of straws when drinking. d. provide heated mist and humidified oxygen.
The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement reflects the most correct teaching?
A. This is a noninvasive test performed to assess your heart rhythm. B. You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease. C. This is a painless test that is done to assess the structure of your heart using sound waves. D. This test evaluates you for potentially fatal cardiac rhythms.