The nurse assesses the postpartum client who delivered 60 hours ago and notifies the RN if which of the following is found?
1. Bright red lochia with a 1 inch by 4 inch stain on the peripad last changed four hours ago
2. Breasts are enlarged and firm to touch.
3. Client is tearful one minute and laughing the next.
4. 2+ reflexes
4
Rationale: 2+ reflexes indicate risk for seizure activity, and should be monitored closely. The nurse should report this to the RN. The other findings are normal postpartum findings for this client.
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The client collects so many newspapers that his garage and the second floor of his house are stacked with them from floor to ceiling. This behavior is known as
1. hoarding. 2. stashing. 3. recycling. 4. collecting.
Which of the following changes in the skeletal system is least characteristic of normal aging?
a. decreased range of motion b. loss of height up to 10 cm c. chronic inflammation of joints d. loss of some muscle mass
A nurse works with a patient with paranoid schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Family members say they feel helpless to foster compliance
Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic preparation b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Prolonged hospitalization; this patient is not ready for discharge
The client diagnosed with heart failure is prescribed enalapril. Which statement explains the scientific rationale for administering this medication?
a. Enalapril increases the level of angiotensin II in the blood vessels. b. Enalapril decreases the effects of bradykinin in the body. c. Enalapril dilates arteries, which reduces the workload of the heart. d. Enalapril blocks the action of antidiuretic hormone in the kidneys.