Culture plays a strong role in determining whether a patient will be willing to communicate if he or she is in pain or how severe the pain may be. Therefore, a nurse understands that extra time may need to be taken to determine the pain level of
1. An older South African woman
2. A young Irishman
3. A young Saudi woman
4. An older Latina woman
ANS: 1
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A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?
a. Client with a core temperature of 95 ° F (35 ° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission
A client has returned from the recovery room after undergoing a urinary diversion. The nurse should monitor the stoma for:
1. blanching. 2. erosion of skin around the stoma. 3. decreased urine output. 4. blood in the urine.
The nurse is caring for a client diagnosed with Parkinson's disease. The nurse is most correct to correlate the client's uncontrolled tremors as a physical characteristic of a lack of which neurotransmitter?
A) Serotonin B) Norepinephrine C) Dopamine D) Acetylcholine
The Apgar score of an infant 5 minutes after birth is 8. Which is the nurse's best interpretation of this?
a. Resuscitation is likely to be needed. b. Adjustment to extrauterine life is adequate. c. Additional scoring in 5 more minutes is needed. d. Maternal sedation or analgesia contributed to the low score.