The client has chronic hypercortisolism. Which intervention is the highest priority for the nurse?
a. Wash the hands when entering the room.
b. Keep the client in protective isolation.
c. Observe the client for increased white blood cell counts.
d. Assess the daily chest x-ray.
A
Excess cortisol reduces the number of circulating lymphocytes, inhibits maturation of macro-phages, reduces antibody synthesis, and inhibits production of cytokines and inflammatory chemicals. As a result, these clients are at greater risk of infection and may not have the expected inflammatory manifestations when an infection is present. The nurse needs to take precautions to decrease the client's risk. It is not necessary to keep the client in isolation. The client does not need a daily chest x-ray.
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Which nursing interventions would best support the family of a critically ill patient?
a. Encourage family members to stay all night in case the patient needs them. b. Give a condition update each morning and whenever changes occur. c. Limit visitation from children into the critical care unit. d. Provide beverages and snacks in the waiting room.
What is the best time for the nurse to assess the peak effectiveness of subcutaneously administered Regular insulin?
a. Two hours after administration b. Four hours after administration c. Immediately after administration d. Thirty minutes after administration
Following a cervical examination of a laboring woman after spontaneous rupture of membranes, the nurse reports that the fetus remains ballottable. Cervical dilatation is 4 cm; cervical effacement is 70%
The most appropriate nursing intervention at this time is to: A) discuss the need for temporary bedrest. B) provide a light diet, and encourage fluids. C) prepare the woman for immediate cesarean delivery. D) begin administration of Pitocin infusion.
When developing a plan of care concerning growth and development for a hospitalized adolescent, what should the nurse do? (Select all that apply.)
a. Stick with one developmental theory for consistency. b. Apply developmental theories when making observations of the individual's patterns of growth and development. c. Compare the individual's assessment findings versus established normal findings. d. Recognize his/her own moral developmental level. e. Apply a unidimensional life span perspective.