The nurse believes a client is experiencing a reaction to a traumatic event when which of the following is assessed? (Select all that apply.)
1. Client is not responding verbally to assessment questions.
2. Client complains of dizziness.
3. Client's blood pressure is 120/80 mmHg.
4. Client complains of nausea.
5. Client asks for medication for a headache.
6. Client asks for something to drink.
1, 2, 4, 5
Common responses to a traumatic event include silence or not responding to verbal stimuli, dizziness, nausea, and headache. A blood pressure of 120/80 mmHg is considered normal. The client requesting something to drink is not a reaction to a traumatic event.
You might also like to view...
The nurse is caring for a client who has inhalation anthrax. What nursing actions are of the highest priority? (Select all that apply.)
a. Placing the client in an isolation room b. Teaching the client how to use a mask c. Teaching the client about long-term anti-biotic therapy d. Using handwashing and other Standard Precautions e. Reporting suspected cases to the proper authorities
A woman is being admitted to your hospital unit for severe preeclampsia. When deciding on where to place her, which of the following areas would be most appropriate?
A) By the nursery so she can maintain hope she will have a child B) Near the elevator so she can be transported quickly C) Near the nurse's station so she can be observed closely D) In the back hallway where there is a quiet, private room
Which of the following statements indicates the nurses understanding of the difference between the electronic health record (EHR) and electronic medical record (EMR) is:
a. "EHR provides nursing with a standar-dized nomenclature of taxonomy to record nursing care.". b. "EMR is the inclusion of only data col-lected by the patient (personal health record (PHR).". c. "EHR is a longitudinal record of the pa-tient's health information.". d. "EMR allows nurses to document nursing care in a system that is intuitive to their level of computer literacy.".
Which immune cell is responsible for releasing Histamine (H1 and H2) during the inflammatory response?
a. Lymphocytes b. Mast cells c. Arachidonic acid d. Macrophages