The mother of a 3-year-old who received a mild concussion during a fall from his tricycle the previous day tells the home health nurse that she is worried about his temperature elevation of 100°
The nurse's best response will be based on the knowledge that the temperature elevation: a. Is an indication of an infection
b. Suggests that there is increasing intracranial pressure
c. Could be a sign that there is an intracranial bleed
d. Is not uncommon during the first 2 days after trauma
D
Mild temperature elevations in young children during the 2 days following a trauma are not uncommon.
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Order: Terbutaline 5 mg/500 mL NS to infuse at 10 mcg/min What is the IV flow rate? _______________
a. 2 mL/hr b. 150 mL/hr c. 60 mL/hr d. 6 mL/hr
An elderly client reports difficulty reading and driving, especially at night. He also reports he has difficulty getting up and down his stairs because "they seem to blend together." Which nursing diagnosis is most appropriate for this client?
a. Sensory/perceptual alterations: sensory deprivation related to therapeutic isolation. b. Risk for injury: falls related to declining vision associated with aging. c. Sensory/perceptual alterations: sensory overload related to hospitalization. d. Altered thought processes related to hospitalization and aging.
The nurse is discussing the risk of falling with a 75-year-old patient's family. The family asks, "Why are you so worried about her falling? She falls all the time and doesn't get hurt much
" The nurse's response will be related to the fact that: 1. falls are the most frequent cause of accidental injury and death among older adults. 2. there probably isn't any need to worry because she wasn't hurt in the past. 3. falls usually occur in institutional settings. 4. falls by older adults are not preventable.
A patient has been advised to add a local sympathomimetic decongestant to the regimen of supportive care for a cold. The nurse should instruct the patient to:
a. expect the effects to be delayed at least 1 week. b. limit the use of this agent to 3-5 days. c. continue the agent until nasal stuffiness has resolved. d. avoid the use of this agent if a fever develops.