A nursing problem relative to John Doe's care is the possibility of injury. Ensuring safety is apriority when caring for a person who might be withdrawing from alcohol
Identify two areas of injury risk, and specify actions you will take to ensure his safety.
• Possibility of bleeding as a result of thrombocytopenia, decreased clotting factors, and esophageal
varices. You should provide a safe environment and observe for evidence of bleeding (e.g.,
hemoglobin/hematocrit [H/H] trends, occult blood in stool, bruising, petechiae, tarry stools,
hemoptysis, hematuria, bloody NGT drainage, epistaxis).
• John Doe's skin integrity might be reduced because of poor nutrition, edema, pruritus, pressure,
friction, and shearing forces. You should monitor his skin for any signs of breakdown, control
pruritus, and turn him every 2 hours, using assistance if needed.
• DTs, an episode of profound alcohol withdrawal that might occur any time between 3 days and a
week after the last drink. Benzodiazepines, such as chlordiazepoxide (Librium), might be used to
prevent seizures.
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A patient has had multiple blood pressure readings that indicate he is hypertensive. How is hypertension defined?
A) Systolic pressure above 140 mm Hg or diastolic pressure above 90 mm Hg B) Systolic pressure above 160 mm Hg or diastolic pressure above 110 mm Hg C) Systolic pressure above 130 mm Hg or diastolic pressure above 95 mm Hg D) Systolic pressure above 150 mm Hg or diastolic pressure above 100 mm Hg
A patient with a serious illness is being cared for in a CCU. Considering energy expenditure during illness and the potential for healing, what is most appropriate nursing action?
A) Maintain complete bed rest with minimal activity B) Ensure complete pharmacological sedation C) Limit visits to immediate family only D) Facilitate nutrition assessment and delivery
The nurse assessing a client with hypopituitarism would note the finding most consistent with this disorder as
a. a pendulous abdomen. b. frequent nasal drainage. c. mottled skin. d. short stature.
Which information will the nurse include when teaching an older patient about skin care?
a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection.