A resident is 55 years old. The person needs rehabilitation after hip replacement surgery. You take the person's temperature orally. Which measurement is abnormal?
a. 98.1° F
b. 99.8° F
c. 98.2° F
d. 98.0° F
B
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The nurse is caring for a patient with schizophrenia who is recovering from open abdominal surgery. The nurse observes the patient grimacing and guarding his abdomen. From the information provided, what priority nursing diagnosis will the nurse formulate
1. Disturbed thought processes due to surgery, evidenced by tachycardia and tachypnea. 2. Acute pain due to surgery, evidenced by facial grimacing, tachycardia, and tachypnea. 3. Acute pain caused by surgery, manifested by facial grimacing, tachycardia, and tachypnea. 4. Disturbed thought processes caused by schizophrenia, manifested by tachycardia and tachypnea.
A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. If the nurse suspects cerebral herniation the most appropriate intervention would be to:
1. Briefly hyperventilate the patient. 2. Take measures to increase intracranial pressures by Trendelenburg positioning. 3. Prepare for emergency surgical repair. 4. Contact the family to come say their last words with the patient.
The mother of an adolescent patient says to the nurse, "I think my son is staying up too late studying, and I see him using Visine eye drops all the time for his red eyes. Should I have his vision checked?" What is the best response by the nurse
1. "He might be depressed; insomnia is common with depression." 2. "Sounds like he is smoking marijuana, and I would talk to him." 3. "Sounds like he is using cocaine; I have seen this before." 4. "Yes, that is a great idea, he may need some glasses."
A client arrives at the healthcare center in a critical state. What step of the nursing process would the nurse have to complete before notifying a physician?
A) Nursing assessment B) Nursing diagnosis C) Planning D) Implementation