A 60-year-old man was admitted for cholecystitis that resulted in a cholecystectomy. On his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100

Based on these findings, what focused assessment should the nurse complete?
a.
Cardiac problems
b.
Respiratory problems
c.
Withdrawal problems
d.
Circulatory problems


ANS: C
Diaphoresis, tremors, and hypertension are all symptoms of withdrawal from alcohol consumption. The nurse, concerned about the patient's medical condition, may not consider substance abuse until withdrawal symptoms appear.

Nursing

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A patient being mechanically ventilated with positive end-expiratory pressure and pressure support totaling 30 mm Hg has developed unequal chest expansion, absent breath sounds on the right, and tracheal deviation to the right

The patient is increasingly tachycardic, anxious, and agitated, and his pulmonary compliance is rapidly decreasing. What is the most appropriate nursing action? A) Obtain a chest x-ray to rule out pneumothorax. B) Inititate needle thoracotomy or chest tube insertion. C) Sedate the patient and evaluate ventilator settings. D) Obtain arterial blood gases to evaluate gas exchange.

Nursing

Your patient has requested a follow-up assessment of his pilonidal disease because of a recent onset of pruritus on his buttocks. To inspect the patient's perineum and sacrococcygeal area, you would position him

a. in the lithotomy position. b. in the left lateral decubitus position. c. bending over the examination table, with his legs spread apart. d. supine, with legs spread apart.

Nursing

During a mock training session, student nurses are taught the acronym "RACE" to be

followed during a fire. What does "C" stand for? A) Can clients walk to safety? B) Call for assistance C) Contain or confine the fire D) Cut out fire using extinguishers

Nursing

Which agency provides coordination in the event of a terrorist attack?

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Nursing