Which finding for a patient who has a head injury should the nurse report immediately to the health care provider?
a. Intracranial pressure is 16 mm Hg when patient is turned.
b. Pale yellow urine output is 1200 mL over the last 2 hours.
c. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
d. Ventriculostomy drained 40 mL of cere-brospinal fluid in the last 2 hours.
ANS: B
The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.
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The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
a. Kidneys b. Liver c. Spleen d. Stomach
The star quarterback on the high school football team is injured in a motorcycle accident. He will be unable to play football again. In planning his care, the nursing diagnosis for coping that you would use is:
1. Impaired physical mobility. 2. Situational low self-esteem. 3. Impaired social interaction. 4. Impaired comfort.
The nurse is assisting a client with limited mobility into position for examination of his prostate gland. How does the nurse best assist the client?
a. Assist the client to bend over the exami-nation table. b. Hold the client up as he bends over the bedside table. c. Help the client lie down in a side-lying fetal position. d. Assist the client to lie in a prone position.
Which of the following are considered internal stressors? Select all that apply
A) loud noises B) pollution C) illness D) hormonal change E) fear F) cold stress