The client reports that the IV site hurts. The nurse assesses the site, and it appears normal, without redness, edema, drainage, or any indication of complications. What is the nurse's priority intervention?
1. Discontinue the infusion.
2. Notify the physician.
3. Slow the rate of infusion.
4. Notify the RN.
4
Rationale: The nurse should notify the RN, who will assess the client further. The infusion should not be discontinued because the discomfort could be caused by caustic solution that might require further dilution. The RN can determine if the physician must be notified, but the rate of infusion should not be decreased until further evaluation of the discomfort can be made.
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The client assessment finding that deserves priority intervention by the nurse working in the
community setting is that the client a. receives Social Security disability income plus a small check from a trust fund. b. lives in an apartment with two clients who attend day hospital programs. c. has a sister who is interested and active in his care planning. d. purchases and uses marijuana on a frequent basis.
How are stress and substance abuse interrelated?
A. The neurotransmitters stimulated by many abused substances enhance the sense of well-being and cause the sensation of stress when the substance wears off. B. Chronic substance abuse leads to destruction of brain cells in the limbic area, causing an increased intensity of the stress response. C. Most abused substances are perceived by the body as physiologic stressors, which result in a heightened "fight-or-flight" response. D. As tolerance or addiction develop, more of the abused substance is needed to achieve the same pleasurable responses.
Which of the following are characteristics of accurately developed client outcomes? Select all that apply
A. Client outcomes are formulated by nurses independent from other team members. B. Client outcomes are not restricted by time frames. C. Client outcomes are specific and measurable. D. Client outcomes are realistically based on client capability. E. Client outcomes are formally approved by the psychiatrist.
Which outcome statement indicates that a client has effectively been treated with conjugated estrogen (Premarin) for severe and frequent hot flashes?
1. The client is able to sleep 4–5 hours every night. 2. The client reports one to two hot flashes per day. 3. The client reports experiencing headaches while taking this drug. 4. The client reports an improvement in mood.