The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for:
1. Signs of hyperglycemia
2. Signs of a bacterial infection
3. The presence of protein in the urine
4. Signs of increased intracranial pressure
4
Rationale: Intracranial pressure and encephalopathy are major symptoms of Reye's syndrome. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.
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The home care nurse is using OASIS information to evaluate outcome measurements for client care. Which data should the nurse use for this evaluation?
1. Client's Braden Skin Assessment score is 12. 2. Client has a stage 2 pressure ulcer on the sacrum. 3. Client admission paperwork completed within 24 hours. 4. Client self-administers insulin and changes foot wound dressing independently.
A client with major depression is having a disturbed sleep pattern. Which of the following nursing interventions will help the client to get maximum sleep during the night?
A) Acknowledge the client's feeling of despair. B) Encourage active exercise before bedtime. C) Encourage the client to go to bed early. D) Keep the client busy during the day.
You are a nurse working on a hospice team. The team is admitting a patient with a diagnosis of stage IV colon cancer. What are the functions of the health care team? (Mark all that apply.)
A) Facilitating the construction of a social support system B) Continually assessing the occupational environment C) Developing interventions created to handle the stressors D) Implementing specified treatment protocols E) Directing multigenerational task assignments
Describe the assessment you need to perform at this time
What will be an ideal response?