Three weeks after a viral illness, a patient has an onset of weakness in the lower extremities that is progressing to the arms. The patient is admitted to the CCU with a diagnosis of rapidly progressing Guillain-Barré syndrome
What is the nursing care priority?
A) Monitor respiratory system closely
B) Prevent hazards of immobility
C) Emotional support for patient and family
D) Control musculoskeletal pain
A
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The nurse is sending a patient home who will remain on anticoagulant therapy. What teaching point does the nurse make when teaching the patient about the drug? (Select all that apply.)
A) "Brush teeth gently with soft bristle brush." B) "Wear or carry a MedicAlert notification." C) "Warning signs of bleeding include fatigue, pallor, and increased heart rate." D) "Treat minor side effects with over-the-counter (OTC) medications." E) "Obtain follow-up lab work regularly as ordered."
The nurse is instructing the client on how to use the client-controlled analgesia (PCA) pump. Which statement made by the client indicates an appropriate understanding of the nurse's instructions regarding the use of the PCA pump?
1. "I will push the button continually until I am pain free." 2. "I will likely overdose on pain medication with the use of the button." 3. "I will let my family control my pain medicine by allowing them to push the button." 4. "I will push the button when the pain becomes severe."
A parent brings a 16-month-old child to the clinic for a well-child checkup. During the assessment, the nurse finds that the child cannot support himself on furniture and does not try to pull himself up from a sitting position
The child is lagging in which of the following processes? A) Behavior B) Growth C) Development D) Height
A client with delirium is attempting to remove the intravenous tubing from his arm, saying to the nurse, "Get off me! Go away!" The client is experiencing which of the following?
a. Delusions b. Hallucinations c. Illusions d. Disorientation