The victim of a motor vehicle accident has been admitted with massive trauma, including traumatic brain injury
Emergency treatment of increased intracranial pressure (ICP) has failed to resolve the problem, and monitoring reveals the ominous presence of Cushing's triad. What assessment findings would be consistent with this clinical phenomenon?
A) PaO2 70 mm Hg; RR 12 breaths per minute; HR 116 beats per minute
B) Temperature 104°F (40°C); RR 33 breaths per minute; HR 111 beats per minute
C) HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute
D) pH 7.2; PaO2 72 mm Hg; HCO3 20 mEq/L
C
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The priority nursing diagnosis for a child with bipolar disorder who has suicidal ideas would be
1. powerlessness related to moodinstability. 2. social isolation related to disorder. 3. risk for injury related to suicidalideas. 4. impaired social interaction.
A nurse is caring for a client who needs assistance while eating. What intervention
should the nurse perform to make this client comfortable during meals? A) Provide thick liquids to the client B) Allow a family member to feed the client C) Teach the client to locate the food on the plate D) Describe the food to the client
Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process?
1. "I work with my ancillary staff to be able to determine what is abnormal." 2. "The skin is easy to observe for abnormalities when you are giving the bath." 3. "I use the time to really look at my clients and determine what's normal and what's not." 4. "Bath time is an excellent time to get to know your clients and form that nurse-client relationship."
The nurse notices redness, swelling, and induration at a surgical wound site. What should the nurses next action be?
a) Assess the clients temperature b) Clean with antiseptic material and re-dress the site c) Notify the health care provider d) Evaluate the clients white blood cell count