A nurse is taking the history of a client with suspected neurologic deficits. The client has experienced diminished central vision over the past 2 months
According to Gordon's Func-tional Health Patterns, what pattern disturbance is this client experiencing? A. Health Perception–Health Management Pattern
B. Cognitive-Perceptual Pattern
C. Self-Care Assistance Pattern
D. Activity-Exercise Pattern
B
According to Gordon's Functional Health Patterns, alterations in sensory functions such as hear-ing and vision reflect disturbances in the Cognitive-Perceptual Pattern.
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A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli
Which documentation of neuromuscular status is most appropriate? A) Abnormal posture B) Flaccidity C) Weak muscular tone D) Decorticate posturing
A newly diagnosed cancer client is crying and states the following to the nurse: "I promised God that I will be a better person if I can just get better." What is the appropriate assessment of this comment by the nurse?
A) The client is just trying to protect self from potential loss. B) Anger directed toward nursing staff is not unusual in dealing with cancer clients. C) The cancer is viewed as a punishment from past actions. D) Loss is inevitable so client is making final plans.
A patient develops ventricular tachycardia on the cardiac monitor. The patient says, "My heart is racing" as the nurse determines a rapid pulse is present. What is the nurse's priority intervention?
1. Call respiratory therapy to prepare a mechanical ventilator. 2. Draw blood for arterial blood gases. 3. Prepare for a change in intravenous fluid being administered. 4. Monitor the patient for loss of consciousness.
What should the nurse anticipate in an infant who was exposed to cocaine during pregnancy?
a. Seizures b. Hyperglycemia c. Large for gestational age d. Hypertonia and jitteriness