A patient is being cared for in the CCU after a ruptured cerebral aneurysm. The nurse finds new onset of hemiparesis, slight lethargy, and complaints of diplopia. What complication does the nurse suspect?
A) Aneurysm rebleed
B) Increased intracranial pressure
C) Cerebral artery vasospasm
D) Carbon dioxide retention
C
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During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After this treatment program, I think everything will be all right.". Which remark by the nurse will be most helpful to the spouse?
a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it.". b. "While sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol.". c. "It will be important for you to structure life to avoid as much stress as you can. You will need to provide social protection.". d. "Alcohol is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully.".
The nurse discussing nutrition with a pregnant woman, would inform the woman that which of the following are good sources of folic acid? (Select all that apply.)
a. Meat d. Yeast b. Eggs e. Apricots c. Legumes f. Green leafy vegeta-bles
A 12-year-old boy with Duchenne's muscular dystrophy is being seen in the clinic for a routine health visit. An appropriate nursing diagnosis for this patient would be
1. Risk for Impaired Mobility related tohypertrophy of muscles. 2. Risk for Infection related to alteredimmune system. 3. Risk for Impaired Skin Integrityrelated to paresthesia. 4. Risk for Altered Comfort related toeffects of the illness.
The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.)
a. Vision b. Hyperemia c. Induration d. Blanching e. Temperature of skin