The nurse observes a client who is becoming increasingly upset. He is rapidly pacing, hyperventilating, clenching his jaw, wringing his hands, and trembling. His speech is high-pitched and random; he seems preoccupied with his thoughts. He is pounding his fist into his other hand. The nurse identifies his anxiety level as
a. Mild
b. Moderate
c. Severe
d. Panic
Ans: c. Severe
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The patient's wound is being treated with vacuum-assisted wound closure (negative pressure therapy, or VAC)
The nurse notices that the edge of the dressing is loose and torn, the foam in the wound has expanded, and wound drainage is leaking through the loose edge. What is the best nursing action? A) Reinforce dressing with additional foam packing. B) Reinforce transparent adhesive dressing. C) Discontinue suction on the wound to prevent maceration. D) Completely redress the wound with new materials.
The nurse is planning to initiate a phone call to the client's physician regarding a change in status. Which of the following should the nurse ensure would be done prior to making the call? (Select all that apply.)
a. Ensure that all lab reports are back. b. Ask another nurse their opinion prior to calling. c. Ask the charge nurse to complete the call for you. d. Wait until the end of the shift and consult with the next nurse. e. Have the client's assessment data available. f. Minimize the chance of interruptions during the call.
A patient is brought to the health clinic complaining of diarrhea and stomach discomfort after ingesting an egg casserole. Which bacterial infection would the nurse suspect this patient of contracting?
A) Escherichia coli B) Salmonella C) Shigella D) Giardia lamblia
The nurse reviews the laboratory tests of a patient receiving heparin therapy for a pulmonary embolism. The aPPT is 50 seconds. The nurse should:
a. notify the prescriber that the dosage should be increased. b. continue the present order because the level is therapeutic. c. withhold the next dose because the level is too high. d. start warfarin therapy because the patient is now heparinized.