A client is brought to the emergency department by his brother. The client has a history of bipolar disorder, for which he is taking valproate. The brother reports that he watched the client take the medication about 2 hours ago
He stated, "A little while ago, he got very disoriented and agitated." The nurse suspects toxicity based on assessment of which of the following? Select all that apply.
A) Tachypnea
B) Bradycardia
C) Hypotension
D) Dizziness
E) Respiratory depression
Ans: C, D, E
Both valproate and carbamazepine may be lethal if high doses are ingested. Toxic symptoms appear in 1 to 3 hours and include neuromuscular disturbances, dizziness, stupor, agitation, disorientation, nystagmus, urinary retention, nausea and vomiting, tachycardia, hypotension or hypertension, cardiovascular shock, coma, and respiratory depression.
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The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings indicate the need for immediate intervention by the nurse?
Select all that apply. A) Retractions and fatigue B) Tachycardia and tachypnea C) Inaudible breath sounds D) Diffuse wheezing and the use of accessory muscles when inhaling E) Reduced wheezing and an ineffective cough
A nurse should plan to implement which interventions for a child admitted with inorganic failure to thrive? Select all that apply
a. Observation of parent–child interactions b. Assignment of different nurses to care for the child from day to day c. Use of 28 calorie per ounce concentrated formulas d. Administration of daily multivitamin supplements e. Role-modeling appropriate adult–child inte-ractions
The nurse is developing a plan of care for an infant being admitted with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. In the preoperative period, the nurse suggests to document in the plan of care to position the child:
1. In an infant seat placed in the crib 2. Prone with the head of the bed elevated 3. Supine with the head at a 90-degree angle 4. Supine with the head of the bed at a 30-degree angle
MC The operation stage of group development is analogous to what stage of the nursing process?
A. Evaluation B. Assessment C. Implementation D. Planning