A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client?
A) Blood pressure 180/98 mm Hg
B) Alert and oriented times three
C) Grade V on the Hunt-Hess Scale
D) Complaint of severe splitting headache
C
Feedback:
The Hunt-Hess Scale is used for grading a client with a cerebral aneurysm and provides the most accurate assessment as listed. An elevated blood pressure is anticipated with a cerebral aneurysm. Being alert and oriented provides little assessment value without additional neurologic data. Complaint of severe headache is subjective and not as significant as the Hunt-Hess Scale.
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Upon admission to the detox unit, the nurse fills the water pitcher with orange juice and administers thiamine injection as ordered by the physician. What is the primary purpose for encouraging ingestion of juice?
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A preschool-age child is being seen in the oncology clinic for a suspected diagnosis of cancer. A common reaction preschool-age children have to a diagnosis of cancer is:
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A 69-year-old patient in the geriatric clinic has an annual physical examination and a complete blood count and serum electrolytes are drawn. While the physical examination was uneventful the laboratory results show an elevated blood urea nitrogen (BUN)
a. Ask that the test be rerun since the client showed no physical signs of renal failure. b. Review the client's medication list since BUN can be affected by many spe-cific medications. c. Instruct the client on collecting a 24-hour urine specimen for a more detailed analysis. d. Assure the client that an elevated BUN is normal in older adults.