The nurse suspects that a patient with ulcerative colitis has taken a dose of diphenoxylate (Lomotil) to help with diarrhea. What did the nurse assess to make this clinical decision?
Select all that apply.
1. fever
2. tachycardia
3. hypotension
4. low urine output
5. abdominal cramps
Correct Answer: 1, 2, 3, 5
Toxic megacolon may be triggered by the use of laxatives by the person with ulcerative colitis. Manifestations of toxic megacolon include fever, tachycardia, hypotension, and abdominal cramps. Low urine output is not a manifestation of toxic megacolon.
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The nurse is caring for a patient diagnosed with anemia. This morning's hematocrit level is 24%. Platelet level is 200,000/microliter. The nurse can expect to:
a. continue monitoring the patient, as this hematocrit is normal. b. administer platelets to help control bleeding. c. give fresh frozen plasma to decrease prothrombin time. d. provide RBC transfusion because this level is below the normal threshold.
The school health nurse is presenting a health-promotion class to a group of middle-school students. Which is the best intervention to address health-promotion strategies related to the leading cause of cancer deaths in North America?
A) Monthly self-breast exams B) Smoking cessation C) Annual colonoscopies D) Monthly testicular exams
When assessing a child for any possible cardiac anomalies, the nurse takes the right arm blood pressure (BP) and the BP in one of the legs. She finds that the right arm BP is greater than that found in the child's leg
The nurse reacts to these findings in which of the following ways? a. charts the findings and realizes they are normal b. suspects the child may have coarctation of the aorta c. places the child in the Trendelenburg position d. notifies the physician and alerts the surgery team
On examining a client's fingernails, the nurse notes that they are excessively dry. The nurse knows that this can be caused by which of the following?
1. Fungal nail infections 2. Dry climates 3. Washing dishes by hand 4. Polishing nails, and using polish remover