Symptoms the nurse should expect to confirm for an individual who has just "shot up" with heroin
are
a. anxiety, restlessness, and paranoid delusions.
b. muscle aching, dilated pupils, and tachycardia.
c. heightened sexuality, insomnia, and euphoria.
d. drowsiness, constricted pupils, and slurred speech.
D
Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased and
attention will be impaired. Option A describes behaviors consistent with amphetamine use. Option B
describes symptoms of narcotic withdrawal. Option C describes cocaine use.
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An elderly patient who is about to have open-heart surgery has verbally instructed the nurse that she does not want her life to be extended by a ventilator after the surgery
The patient's advance directive, however, indicates that she would prefer to receive all life-support measures. The nurse suspects that the patient has dementia. Which of the following questions would be most appropriate for the nurse to ask in the assessment stage of ethical decision making? A) What are the ethical issues related to continuing or removing life-support measures for this patient? B) Who should be involved in making the decision regarding life-support measures for this patient? C) Is this patient mentally competent to make decisions about use of life support? D) What educational changes can be made in the ICU to resolve similar ethical challenges related to life support measures in the future?
The nurse is caring for a client who has smoked for many years and documents that "clubbing is present." Which technique is the best way for the nurse to determine the presence of clubbing?
1. Place two thumbs touching side-by-side. 2. Place two of the same fingers from each hand together. 3. Place two index fingers together tip-to-tip. 4. Place the hands out straight with the palm sides down.
The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated?
1. Encourage the patient to ingest more fluids. 2. Assess for pain and warmth. 3. Cover the wound with a sterile dry dressing. 4. Dress the wound as prescribed.
By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily:
1. Recognizing the patient as an active participant in her own care. 2. Attempting to correct any misinformation the patient might have received. 3. Acting as an advocate for the patient. 4. Establishing rapport with the patient.