The nurse is helping a pregnant patient being seen for injuries caused through intimate partner violence create a safety plan. What should be included in this plan? (Select all that apply.)
A) Learn self-defense
B) Copy all utility bills
C) Have access to driver's license
D) Make a list of important telephone numbers
E) Pack bag with cash, credit cards, and clothing
Ans: B, C, D, E
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The nurse recommends the influenza vaccination to a 72-year-old woman who is the primary caregiver of her elderly mother who has Alzheimer's disease. Which instruction should the nurse include in the teaching plan for this vaccine?
A) The vaccine is not needed because chronic stress boosts the immune response. B) Older adult caregivers have an accentuated immune response to influenza vaccine. C) Chronic stress may blunt the efficacy of the influenza vaccine in older adults. D) The effects of chronic stress on the immune system improve immediately when the stress is removed.
The nurse evaluates no need for further instruction for self-care for the patient with Cushing's syndrome who states:
1. "I know I should add salt to everything I eat." 2. "I make a point to avoid excessive exposure to sun." 3. "I avoid being exposed to anyone with an infection." 4. "I am careful to wear well-fitting shoes."
When analyzing a client's electrocardiograph (ECG) tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurse's interpretation of this observation?
a. The client has hyperkalemia causing irre-gular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.
What type of facial paralysis does he have?
A 41-year-old real estate agent comes to your office, complaining that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy and as the day progressed he was unable to close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. His past medical history is unremarkable. He is divorced and has one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination you ask him to close his eyes. He is unable to close his left eye. You ask him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. You then ask him to give you a big smile. The right corner of his mouth raises but the left side of his mouth remains the same. A) Peripheral CN VII paralysis B) Central CN VII paralysis