A military veteran is being evaluated for traumatic brain injury (TBI). Which nursing assessment data supports such a diagnosis? (Select all that apply.)
a. Baseline blood pressure is 148/96
b. Has been treated for bronchitis twice in the last 8 months
c. Patient reports experiencing an average of 3 headaches per week
d. Petit mall seizure activity well controlled with antiseizure medication therapy
e. Patient reports a weight gain of 15 pounds since returning from deployment 12 months ago.
C, D, E
Physiological problems related to TBI can include headache, seizures, as well as appetite and weight changes. The remaining options, hypertension and respiratory infections, are not generally occasioned with TBI.
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The nurse is calculating intake and output for a client. Intake included 1750 ml of D5W, 500 ml of ceftriaxone, 8 oz of coffee, 4 oz of juice, and 800 ml of water. The client’s output included 1560 ml of urine, and 45 ml of vomitus. What is the total output for this client? Record your answer using a whole number. _________ml
a. 3460 ml b. 2410 ml c. 1874 ml d. 1605 ml
A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next?
1) Perform the Get Up and Go Test. 2) Ask the patient if he has fallen in the past year. 3) Refer the patient for a comprehensive fall evaluation. 4) Administer the Timed Up and Go Test.
A patient is in isolation in a negative-pressure room for tuberculosis, and the nurse notes that the respirator mask is damaged slightly. What is the initial action that the nurse should take?
a. Ask to switch the assignment. b. Check the mask for a tight seal. c. Borrow a mask from a co-worker. d. Use the mask if damage is minor.
Which of the following should the nurse assess to determine if a client's intravenous infusion has infiltrated?
1. A blood return 2. Size of extremity 3. Presence of pain 4. Presence of a temperature