A patient with long-standing hypertension has a viral upper respiratory illness and is self-medicating with over-the-counter medications
The patient complains of severe dyspnea with activity and has new-onset crepitant rales and pitting edema of the lower extremities. In evaluating the patient's medications, what medication should the nurse look for in particular?
A) Furosemide (Lasix)
B) Nonsteroidal anti-inflammatory medications (NSAIDs)
C) Hydrochlorothiazide diuretic (HCTZ)
D) Angiotensin-converting enzyme (ACE) inhibitor
B
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In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements regarding the testing of this reflex are true? (Select all that apply.)
a. Doll's eyes absent indicate a disruption in normal brainstem processing. b. Doll's eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.
The nurse believes that a client is eligible as a participant for The National Hospice Reimbursement Act of 1986. This act mandated that:
1. clients with terminal illnesses are reimbursed. 2. a physician must order hospice to be reimbursed. 3. to receive reimbursement that client must be eligible for Medicare. 4. to receive benefits, the physician must certify that the client has a limited life expectancy of 6 months or less.
A nurse is talking with a 57-year-old client who has been a heavy drinker for many years. The client is being treated for alcoholism, and this is her second week as an inpatient on the psychiatric unit
It is 5:00 AM, and the client has been having difficulty sleeping. The client is an orthopedic nurse, and although she is clothed in a hospital-issued gown and robe, she is wearing a stethoscope around her neck that the nurse recognizes as belonging to one of the staff nurses. When the nurse asks her why she is wearing the stethoscope and where she got it, the client gives her a long and involved reply that basically describes how her nursing supervisor came to visit and gave it to her to wear "so she'd remember to get well." The nurse suspects that the client may be experiencing which of the following? A) Wernicke's syndrome B) Delirium tremens C) Korsakoff's psychosis D) Malignant hyperthermia
What are the advantages of the situation, background, assessment and recommendation (SBAR) documentation format to nursing?
A) It is a concise and effective means of communicating interprofessionally B) It minimizes miscommunication and strengthens the nursing role professionally C) It allows nurses to document care in an individualized and professional manner D) It is similar to the nursing process and so allows for a seamless method of communication