An acutely ill patient is receiving in the hospital's critical care unit. In addition to being delirious, the patient is simultaneously exhibiting significant signs of anxiety
The critical care nurse should recognize that this patient has a heightened risk of having what nursing diagnosis?
A) Risk for Aspiration
B) Risk for Impaired Skin Integrity
C) Risk for Injury
D) Risk for Imbalanced Body Temperature
C
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When assessing community needs, where should the nurse be aware that domestic violence is found?
1. All strata of society 2. Exclusively among the less well-educated segment of the population 3. Primarily in lower-income families 4. Mostly in the elderly
A 69-year-old patient reports a burning, aching pain in the legs when walking to the mailbox. These symptoms are relieved with rest. What should the nurse suspect?
a. Venous insufficiency b. Claudication c. Phlebitis d. Rest pain
The nurse in the walk-in clinic assesses a small piece of rock embedded in the right eye of a man who was breaking up rocks with a sledge hammer. The most appropriate action by the nurse would be to:
a. flush the eye with a continuous stream of warm water. b. instill artificial tears and cover the injured eye with a dressing. c. irrigate the eye with cool water and apply a pressure dressing. d. cover both eyes with a dressing and refer to the physician.
A child is brought to the healthcare provider's office. The child has been receiving phenytoin (Dilantin) for seizure activity
The family reports that despite the child's previously reported controlled seizures, the child has been seizing two or three times a day. The nurse would anticipate that the: a. child's medication will be changed. b. child will be admitted to the hospital. c. child will be placed on nasogastric medications. d. child's phenytoin level will be drawn.