A patient with a right temporal lobe hematoma is displaying Cheyne-Stokes respirations. How should this nurse interpret this assessment finding?
1. The next sign will likely be sluggish pupil reaction ipsilaterally.
2. This type of brain pathophysiology is usually self-limiting.
3. This patient requires surgical decompression of the brain.
4. There is no medical treatment appropriate for this symptomology.
3
Rationale 1: This patient is experiencing a symptom of uncal herniation. Cheyne-Stokes respiration is a late sign. Ipsilateral pupillary changes would have already occurred.
Rationale 2: Herniation syndromes are life-threatening neurologic emergencies that, left untreated, can progress rapidly to death.
Rationale 3: Urgent surgical intervention to decompress the brain is often the treatment of choice.
Rationale 4: Urgent medical treatment may correct the condition causing this symptomology.
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a. Suggest the client attend Alcoholics Anonymous meetings. b. Suggest that the client eat larger portions of food at mealtimes. c. Tell the client's spouse to monitor the client's response. d. Tell the client an adverse reaction to the new drug may occur if alcohol is not eliminated.
A nurse is writing a care plan for a patient with a nasogastric tube in place for gastric decompression. What risk nursing diagnosis is the most appropriate component of the care plan?
A) Risk for Excess Fluid Volume Related to Enteral Feedings B) Risk for Impaired Skin Integrity Related to the Presence of NG Tube C) Risk for Unstable Blood Glucose Related to Enteral Feedings D) Risk for Impaired Verbal Communication Related to Presence of NG Tube
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Which of the following would the nurse include in the plan for this family? 1. Meals-on-Wheels 2. Respite care 3. Food stamps 4. Psychological counseling
The continuous quality improvement (CQI) committee has performed a retrospective chart audit to investigate whether outcomes recorded in each nursing care plan are patient centered and written in behavioral terms
The expected standard is 98% compliance. The sample size was 200 . Results showed that 180 charts met the standard. What assessment can be made? a. The standard was met. No action plan is necessary. b. The standard was not met, but no action plan is necessary because the rate of com-pliance was close to the standard. c. The standard was not met. An action plan should be developed. d. The standard was not met. An immediate re-audit is necessary.