A patient is admitted to the hospital with a severe headache and photophobia. A lumbar puncture confirms a bleeding aneurysm
What nursing interventions should the nurse anticipate assisting with to prevent increased intracranial pressure (ICP) during the acute phase of illness?
a. Morphine, dark glasses, and expectorants
b. Quiet room, head of bed up, and stool softeners
c. Coughing and deep breathing exercises and tranquilizers
d. Range of motion exercises, bedside commode, and suctioning as needed
ANS: B
A quiet room with minimal stressors, elevated head, and stool softeners can help reduce ICP. A. C. Morphine and tranquilizers are not usually recommended because they can make neurological assessment difficult. A. C. Expectorants can promote coughing, which can raise ICP. C. D. Exercises, moving, and suctioning can also raise ICP.
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The primary muscles of respiration include the:
a. Diaphragm and intercostals. b. Sternomastoids and scaleni. c. Trapezii and rectus abdominis. d. External obliques and pectoralis major.
A psychiatric forensic clinical specialist is working with a defendant as competency evaluator
A staff member at the mental hospital asks her, "Why are you spending so much time with that guy? You spend one-to-one time with him and even go to activities with him. And I have seen you writing volumes. Usually we just give these people medication for a while and return them to the court.". What response by the psychiatric clinical specialist would be most appropriate? a. "My role is to become an advocate for the defendant, so I have to know him well and build a trusting relationship with him.". b. "The specialized assessments I make on behalf of the court require very lengthy and detailed interviews, so it takes a lot of time.". c. "My focus is providing intensive psychotherapy to ensure the defendant has become competent before he returns to court.". d. "I spend the time observing, assessing, and documenting his competency, write a report, and prepare expert testimony for the court.".
The nurse is assessing a patient's stool and notes that the color is red. While the red color does not appear to be blood, the nurse performs a hemoccult test on the stool that is found to be negative
The nurse asks the patient if he has recently consumed which of the following foods that may turn the stool red? A) Beef B) Carrots C) Spinach D) Catsup
When the female patient undergoes intracavitary brachytherapy, the patient should be instructed to:
A) Encourage her children to visit. B) Deep breathe and cough every 2 hours. C) Consume a high-residue diet. D) Keep the head of the bed no higher than 45 degrees.