The nurse is caring for the client who has been just admitted with chronic pain and sleep disorders. The nurse plans the care based on the nursing diagnosis pain
Which of the following symptoms, as reported by the client, leads the nurse to this diagnosis? 1. Tender points in the hip
2. Acute chest pain
3. Pain from a severe skin rash
4. Pain from eyestrain
1. Tender points in the hip
Rationale: Clients with fibromyalgia typically complain of multiple tender points generally in the neck or spine. Acute chest pain, pain from a rash, and muscle strain of the eye are not reported symptoms.
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The transfer of tissue between genetically identical individual (twins) is a(n) ________
ANS:
Ranitidine (Zantac) is prescribed for a client with a gastric ulcer. The statement that best indicates to the nurse that the client understands the action of this drug is
a. "I will take this medication at bedtime to relieve pain." b. "Ranitidine will activate protective mucous barriers." c. "Stomach acids are neutralized by this medication." d. "This drug reduces the acid in my stomach."
When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation, which include:
a. A regular heart rate and hypertension. b. An increased urinary output, tachycardia, and dry cough. c. Shortness of breath, bradycardia, and hypertension. d. Dyspnea; crackles; and an irregular, weak pulse.
To find the heart rate from an ECG strip of a patient with a normal sinus rhythm, the nurse counts 20 small boxes between two R waves. The heart rate would be:
A) 75 beats/min B) 80 beats/min C) 60 beats/min D) 140 beats/min