A client who is experiencing an acute asthmatic attack receives prescribed therapy with a bronchodilator. As part of the plan of care, the nurse would continue to assess which of the following every 4 hours? Select all that apply
A) Intake
B) Blood pressure
C) Output
D) Lung sounds
E) Accessory muscle use
Ans: A, C, D, E
Feedback:
The nurse should note the client's respiratory rate, lungs sounds, intake, and output and use of accessory muscles in breathing every 4 hours during an acute asthma attack.
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A nurse is instructing parents about health and nutrition. She states that overweight children are more likely than normal-weight children to develop which disease process?
A) Glaucoma B) Migraine headache C) Scoliosis D) Diabetes mellitus
The psychiatric nurse should plan interventions based on the knowledge that clients may be
intolerant of, or resistant to, common procedures such as vital signs, blood glucose monitoring, or insulin administration. Common reasons for resistance include (more than one answer may be correct) A. anxiety. B. obstinacy. C. lack of trust. D. thought impairment.
A clinic nurse is caring for a patient diagnosed with migraine headaches. When doing patient teaching, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about alcohol's effects?
A) Alcohol causes hormone fluctuation. B) Alcohol causes vasodilation of the blood vessels. C) Alcohol has an excitatory effect on the CNS. D) Alcohol diminishes endorphins in the brain.
Your client is in postanesthesia care unit (PACU) and is complaining of pain he rates as 9 on a scale of 10. You gave him pain medication 1 hour ago. What is the most important thing to be aware of at this time?
1. The client does not know how bad his pain is because of his postanesthesia status. 2. The most important information is the client's report of pain. 3. It is too soon to give the client more pain medication. 4. Wait for 30 minutes to see whether the client's pain decreases.