The nurse is assessing a nervous 18-year-old patient who has vital signs of P 120, R 30, and BP 160/90 . Based on this data alone, the nurse identifies the level of anxiety as:
a. mild.
b. moderate.
c. severe.
d. panic.
C
Severe anxiety may be manifested by elevated vital signs.
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The parents of a chronically ill 8-year-old do not want him to go outside and play or to attend his friends' birthday parties for fear he will become ill. What response by the nurse is most appropriate?
A. "Can you let one or two friends come over to play?" B. "Children his age need to maintain friendships." C. "He can go outside if he wears a mask all the time." D. "You are right to be concerned that he will get sick."
A nurse notices that, even with intermittent suctioning, an NPO client's nasogastric tube is becoming obstructed. Which of the following interventions will promote tube patency?
A) Give liberal amounts of water to the client. B) Inspect the tube carefully. C) Give ice chips to the client. D) Remove and wash the tube.
A critically ill patient requires IV insulin for persistent hyperglycemia. Current fingerstick blood glucose is 68 mg/dL. According to international critical care guidelines, which nursing intervention is indicated?
1. Call for a laboratory glucose test. 2. Increase the rate of the insulin drip by 2 units per hour. 3. Administer 10 mL of D5W by bolus injection. 4. Administer 0.5 g sugar dissolved in orange juice by mouth.
The client just diagnosed with hyperpituitarism and acromegaly is scheduled for a hypophy-sectomy. Which statement made by the client indicates a need for clarification regarding this treatment?
A. "I will drink whenever I feel thirsty after surgery." B. "I'm glad there will be no visible incision from this surgery." C. "I hope I can go back to wearing size 8 shoes instead of size 12." D. "I will wear slip-on shoes after surgery so I don't have to bend over."