Which of the following is a goal statement?
1. Perform skin/wound management.
2. State the signs and symptoms of a wound infection.
3. wound healing: primary intention
4. alteration in skin integrity
ANS: 2
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A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA)
Which nursing action is most important in the management of DKA? A) Give prescribed antiemetics. B) Begin fluid replacements. C) Administer prescribed dose of insulin. D) Administer bicarbonate to correct acidosis.
A patient is admitted to a hospital for treatment for first-time symptoms of mania and is exhibiting euphoric mania. Which medication will the provider order?
a. Lithium [Lithobid] b. Olanzapine [Zyprexa] c. Risperidone [Risperdal] d. Divalproex sodium [Valproate]
A depressed patient shares with the nurse that he, "has been thinking about ending it all". Based on NANDA recommendations, the nurse:
a. Implements suicide precautions for this patient b. Includes ‘Risk for Self Harm' to the patient's care plan c. Documents regarding the patient's safety every 15 minutes d. Reviews the patient's chart for references to past incidences of hopeless
While you are assessing the vital signs of a pregnant woman in her third trimester, the patient complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate?
a. Have the patient stand up and retake her blood pressure. b. Have the patient sit down and hold her arm in a dependent position. c. Have the patient lie supine for 5 minutes and recheck her blood pressure on both arms. d. Have the patient turn to her left side and recheck her blood pressure in 5 minutes.