The extremely stressed woman is in the ER after a car wreck. She is breathing rapidly and complains of dizziness and tingling in her extremities and says, "I think I am having a heart attack!" The nurse recognizes these complaints as being related to:
a. a transient ischemic attack.
b. hyperventilation.
c. hypotension.
d. asthma.
ANS: B
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A nurse is going to visit a client who needs assistance with personal hygiene and feeding. Which of the following suggestions should be made to the family?
a. "I'll teach you how to care for your family member to keep him comfortable or, if you can afford it, you can employ an aide." b. "It's important that he try to take care of himself and, if he can't or won't, he'll have to deal with the consequences." c. "Reimbursement is available for a nurse to come to the house each day if you would like this assistance." d. "You can always have your family member readmitted to the hospital for care."
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
A) Insert an airway or bite block. B) Manually restrain the extremities. C) Turn client to side-lying position. D) Monitor vital signs.
The pediatric nurse is aware that frostbite results from exposure to extreme cold for a minimum of:
A) 30 minutes. B) 60 minutes. C) 90 minutes. D) 120 minutes.
The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient
a. inserts the irrigation tubing 4 to 6 inches into the stoma. b. hangs the irrigating container 18 inches above the stoma. c. stops the irrigation and removes the irrigating cone if cramping occurs. d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.