Regina Smith is a 25-year-old primigravida in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction
Suddenly Regina pushes her husband's hand away and shouts, "Don't touch me!" This behavior is most likely: a. normal and related to hyperventilation.
b. common during the transition phase of labor.
c. a sign that she needs analgesia.
d. indicative of abnormal labor.
B
The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability.
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The nursing care priority in the post-septoplasty client is to:
a. contain bloody drai-nage c. manage client's an-xiety b. maintain patent air-way d. assess for bruising
The prehospital nurse is screening several people injured in a store robbery. Of those injured, the nurse should encourage which one to seek additional care at the nearest emergency department?
1. Male in his mid-20s who had several light boxes of products fall on him while the robbers ran through the store 2. Teenage female who took cover under a shelving unit and sustained a scratch on her arm 3. Middle-age female who crouched down in a corner of the room and strained her knee 4. Elderly male who was briefly unconscious
A client is admitted with a diagnosis of bipolar disorder. This client is dressed in a flowing purple robe. The nurse who conducts the admission interview asks this client if he believes that he has extraordinary abilities or powers
The nurse is assessing for which of the following symptoms? a. delusions of persecution b. ideas of reference c. grandiosity and inflated self-esteem d. flight of ideas
While providing oral medications to a patient recovering from a stroke, the nurse notices that the patient coughs repeatedly and has difficulty clearing the throat. What should the nurse do?
1. Change the diet to full liquid. 2. Change the diet to soft. 3. Request a physical therapy consult. 4. Request a swallowing evaluation by speech therapy.