While obtaining a symptom analysis from a client who has an inner ear infection affecting the acoustic cranial nerve (CN VIII), the nurse helps the client distinguish between dizziness and vertigo. Which description by the client indicates vertigo?
a. "I felt light-headed when I stood up."
b. "I just could not keep my balance when I sat up."
c. "It seemed that the room was spinning around."
d. "I was afraid that I was going to lose consciousness."
ANS: C
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The nurse is assigned to watch the cardiac monitors in the constant care unit and notes four different patients displaying arrhythmias. Which arrhythmia is the nurse's highest immediate priority?
A) Sinus bradycardia at a rate of 54 beats/min B) Atrial flutter C) Sinus tachycardia at a rate of 108 beats/min D) Ventricular fibrillation
The nurse instructs the patient about MAO inhibitors before discharge. The nurse tells the patient to avoid certain foods and beverages while she is on the MAO inhibitors, because they could:
1. cause an increase in appetite leading to obesity. 2. produce severe psychosis. 3. increase depressive behavior. 4. produce sudden and severe hypertension.
A patient is admitted with bleeding from the gastrointestinal tract. The fluid volume compartment that will be effected first in this patient will be
1. intracellular. 2. intravascular. 3. interstitial. 4. transcellular.
In opening a new dialysis unit, the nurse manager has to develop a philosophy for the unit. This philosophy needs to:
a. Reflect the culture of the unit and its values. b. Be developed by the nursing manager on the unit. c. Identify the clients that will be served on the unit. d. Replicate the organization's philosophy.