While you are getting John doe settled, you continue your assessment
What will be an ideal response?
Neurologic findings: PERRL (Pupils Equal, Round, Reactive to Light), moves all extremities, but
patient is sluggish, pulling away during assessment, and follows commands sporadically.
Cerebrovascular findings: Pulse is regular without adventitious sounds. All peripheral pulses are
palpable at 3+ bilaterally; 3+ pitting edema in lower extremities.
Respiratory assessment: Breath sounds decreased to all lobes, no adventitious sounds audible,
patient not cooperating with cough and deep breathing, and Spo2 at 90% on room air.
Gastrointestinal (GI) assessment: Tongue and gums are beefy red and swollen, abdomen is
enlarged and protuberant, and abdominal skin is taut and slightly tender to palpation. Salem
Sump NGT is patent, connected to LCS with small to moderate greenish drainage; bowel
sounds positive with NGT clamped.
Genitourinary (GU) assessment: Foley to gravity drainage, with 75mL dark amber urine past 2 hours.
Skin: Pale on torso and lower extremities; heavily sunburned on upper extremities and head.
Skin appears thin and dry. Numerous spider angiomas are found on the upper abdomen with
several dilated veins across abdomen.
Vital signs: 120/60, 104, 32, 99.1° F (37.3° C).
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Lungs are clear to auscultation with no peripheral edema noted. Which of the following treatments would the physician most likely order? a. Lasix 40 mg intravenous push c. Dopamine 15 ?g/kg/min b. 0.9% normal saline at 125 mL/hr d. Transfuse 1 U of packed red blood cells
A male client experiences a phobia of enclosed spaces (claustrophobia) and is seeking an energy-based therapy that he can practice and initiate on his own when he experiences symptoms. Which therapy will the nurse recommend?
a. Music and sound therapy b. Relaxation and visualization c. Hypnosis therapy d. Spiritual healing
The implementation of the use of clinical pathways in hospitals had what effect on current nursing practice?
A) Decreased the autonomy of nurses in practice B) Increased the variance of care in nursing practice C) Increased the complexity of nursing care D) Decreased the individualization of nursing care plans
What 1819 invention greatly reduced the fear of being buried alive?
a. The EKG b. The stethoscope c. The X-ray d. The lethal injection