What further assessment data do you need to collect?
What will be an ideal response?
Measure T.W.'s vital signs, evaluating for hypertension and bradycardia; assess for vision changes
and nasal congestion; and inspect for pallor or goose bumps below the level of injury. Assess for
potential causes, including urinary concerns, such as bladder distention, obstruction, infection,
spasms, catheterization; bowel constipation, impaction, or rectal stimulation; and alterations in skin
integrity, including pressure, pressure ulcers, infection, injury, and exposure to cold or hot.
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The patient is scheduled for a painful procedure. In addition to premedicating the patient with an opioid drug, what other nursing action is most likely to alleviate the pain?
A) Give intravenous midazolam (Versed). B) Monitor vital signs during the procedure. C) Give explanations before and during the procedure. D) Ask the family to wait outside during the procedure.
The nurse is caring for a client on a monitored telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the telemetry monitor. Which action would the nurse do first?
A) Call the physician with a report. B) Assess the client. C) Assess for mechanical dysfunction. D) Reposition the client.
The nurse explains that the three cardinal signs of type 1 diabetes mellitus are __________, __________, and __________
Fill in the blank(s) with correct word
You watch a child arranging sugar packets from his meal trays in order of their weight. This activity of conservation is most typical of what age child?
A) Toddler B) Preschooler C) School age D) Adolescent