The patient's initial vital signs immediately on return from surgery include: blood pressure (BP) of 140/90; pulse (P) of 80; respirations (R) of 14; and temperature (T) of 98° F
One hour later the vital signs are: BP of 130/84; P of 72; R of 16; and T of 96.8° F. What action should the nurse take next?
a. Add a blanket for warmth to the patient.
b. Notify the charge nurse of a probable he-morrhage.
c. Raise the head of the bed 45 degrees.
d. Document the assessment findings.
D
These findings are normal. The nurse should document the normal recovery assessment and con-tinue to monitor. There is no indication of chilling, hemorrhage, or respiratory distress, which respectively would require blanket application, charge nurse notification, or raising the head of the bed.
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The nurse is giving discharge instructions to a client who had a total abdominal hysterectomy. Which statements by the client indicate a need for further teaching? (Select all that apply.)
a. "I should not have any problems driving to see my mother, who lives 3 hours away." b. "Now that I have time off from work, I can return to my exercise routine next week." c. "My granddaughter weighs 23 pounds, so I need to refrain from picking her up." d. "I will have to limit the times that I climb our stairs at home to morning and night." e. "For 1 month, I will need to refrain from sexual intercourse."
A patient with a serious illness is being cared for in a CCU. Considering energy expenditure during illness and the potential for healing, what is most appropriate nursing action?
A) Maintain complete bed rest with minimal activity B) Ensure complete pharmacological sedation C) Limit visits to immediate family only D) Facilitate nutrition assessment and delivery
Which intervention would help a client who is demonstrating stress about being hospitalized and concerned about the needs of the children at home?
A) Ask the client if there is anything that is needed once discharged to home. B) Ask the client if there is anyone who would be able to help with the family needs at home during recuperation. C) Find out if the children can be sent to a grandparent's home until the client fully recovers. D) Suggest the client be transferred to a long-term care facility to ensure a full recovery.
A client who has been taking antidepressant medication for several months and is demonstrating an improvement in symptoms tells the nurse that counseling sessions might be helpful. Which types of therapies will the nurse review with the client?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Behavioral therapy 2. Interpersonal therapy 3. Cognitive–behavioral therapy 4. Psychodynamic therapy 5. Crisis therapy