The patient has undergone intracerebral surgery. Knowing that interruption of the skull interferes with the brain's ability to autoregulate, what nursing assessment information most clearly indicates the highest patient risk?
A) Pulmonary adventitious sounds
B) Capillary refill less than 2 seconds
C) Blood pressure consistently elevated
D) Pain at 8 on 0-to-10 scale
C
You might also like to view...
The nurse is reinforcing teaching for a patient who has had a right total hip replacement. Which of the following statements by the patient would indicate a correct understanding of the teaching?
a. "Keep legs apart." b. "Move right leg closer to the left leg." c. "Do not bear any weight on the left leg." d. "Lie prone in bed."
The admissions department at a local hospital is registering an elderly man for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive
The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this patient? A) "Advance directives are not legal documents, so you have nothing to worry about." B) "Advance directives are limited only to health care instructions and directives." C) "Your finances cannot be managed without an advance directive." D) "Advance directives are implemented when you become incapacitated, and then you will use a living will to allow the state to manage your money."
A faculty member is explaining to the senior nursing class that to become licensed, applicants must (Select all that apply.)
a. demonstrate good moral character. b. graduate from an approved program. c. maintain a certain grade point average. d. pass the standard licensure examination.
Enabling moves the patient toward independence and good mental health.
Answer the following statement true (T) or false (F)