The nurse notes all of the following changes in the last week in a 72-year-old nursing home patient taking nortriptyline (Pamelor) for chronic pain. For which problem does the nurse imme-diately notify the prescriber?
a. Heart rate decreased from 80 to 72 beats per minute
b. Respiratory rate decreased from 20 to 16 breaths per minute
c. Weight increased from 128 to 137 pounds
d. Morning blood glucose increased from 86 to 94 mg/dL
C
Nortriptyline is an antidepressant. These drugs can make heat failure worse and can cause urinary retention. Fluid retention with weight gain is a symptom of worsening heart failure. A weight gain of 9 pounds in a week is significant and an indicator of rapidly worsening heart failure.
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The nurse is assessing a client's visual fields by confrontation. Which of the following nursing actions indicates that the nurse requires further education regarding this test?
1. The nurse asks the client to cover one of her eyes with a card. 2. The nurse uses a penlight to assist with performing the test. 3. The nurse asks the client to sit 20 feet away. 4. The client tells the nurse when she first sees the object.
A woman is admitted for repair of cystocele and rectocele. She has nine living children. In taking her health history, which of the following would the nurse expect to find?
A) Sporadic vaginal bleeding accompanied by chronic pelvic pain B) Heavy leukorrhea with vulvar pruritus C) Menstrual irregularities and hirsutism on the chin D) Stress incontinence with feeling of low abdominal pressure
Which of the following symptoms may also be an objective symptom?
1. Tinnitus 2. Vertigo 3. Otalgia 4. Presyncope
A nurse is being sued for malpractice. Which of the following specific elements must be present for the nurse to lose the case? (Select all that apply.)
______ Negligence ______ Damages ______ Injury ______ Malpractice ______ Causation ______ Foreseeability ______ Breach of duty ______ Duty