The nurse is caring for a patient who is being treated for cerebral vasospasm with a medical treatment known as triple-H therapy
Which assessment data confirm that the treatment is currently effective? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Mean arterial pressure (MAP) 110 mmHg
2. Hematocrit 34%
3. Sodium of 125 mg/dL
4. Urine output 40 ml/hr
5. BP 170/96
1,2,3,5
Rationale 1: Mean arterial pressure (MAP) should be between 60 and 150 mmHg.
Rationale 2: Hematocrit should be greater than 30% to reflect good cerebral perfusion.
Rationale 3: Sodium level is not an assessment value used to monitor triple-H therapy.
Rationale 4: Urine output is not considered an assessment value for monitoring triple-H therapy.
Rationale 5: Triple-H therapy consists of hypertension, hemodilution, and hypervolemia. The goal of triple-H therapy is to increase cerebral perfusion pressure and CBF, therefore reducing the risk for further neurological deficits. Systolic blood pressure should be kept at no less than 160 mmHg.
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The nurse is told that the client most likely has the diagnosis of obsessive-compulsive disorder. The nurse is not sure of the assessment data and behaviors that accompany this disorder
Which action would be most appropriate for the nurse to take? 1. Document all subjective and objective data provided by the client. 2. Ask the primary health provider to identify needed subjective and objective assessment data. 3. Research obsessive-compulsive disorder in the medical dictionary. 4. Consult the Diagnostic and Statistical Manual of Mental Disorders for diagnostic criteria.
The nursing assessment of a pressure ulcer includes size, depth, pain, odor, and color of tissue to evaluate:
a. treatment needed. b. effectiveness of implementation. c. whether improvement is occurring. d. need for additional interventions.
The nurse is planning care for a patient with a chronic illness. What intervention should the nurse include in the plan of care?
1. Instruct the patient in ways to minimize the impact of the chronic illness on activities of daily living. 2. Encourage the patient to seek medical care with any changes in symptoms. 3. Limit activities until symptoms subside.
The patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move his right arm and leg. The nurse understands that
a. Active range of motion is the only thing that will prevent contractures from forming. b. Passive range of motion must be instituted to help prevent contracture formation. c. Range-of-motion exercises should be started 2 days after the patient is stable. d. Range-of-motion exercises should be done on major joints only.