Intracranial pressure monitoring can be a valuable diagnostic tool but also has significant complications. In what patient with a severe head injury would the nurse question the use of intracranial pressure monitoring?
A) Glasgow Coma Scale score of 3
B) Declared brain dead
C) Subarachnoid hematoma
D) Severe stroke
B
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A patient born in a European country speaks excellent American English. The nurse realizes that this patient has achieved which type of assimilation?
A. Cultural B. Marital C. Primary structural D. Secondary structural
During the assessment of a client, the nurse finds that the client's lower extremities are both warm, sensation is intact, and motion is unrestricted. What does this finding suggest to the nurse?
A) Skeletal muscle attached to bones via tendons is performing correctly. B) Smooth muscle attached to bones via ligaments will require further assessment. C) Cartilage connecting bones has a good blood supply. D) Muscle connecting the axial skeleton is compromised.
The nurse is caring for a child whose medical chart indicates a grade III murmur. Which of the following assessment findings would the nurse expect when auscultating heart sounds?
A) Loud without a thrill B) Loud with a precordial thrill C) Soft and easily heard D) Loud, audible with a stethoscope
What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? Select all that apply
a. It must be given with D5 1/2NS. b. The child will require monitoring of therapeutic serum levels while taking this medication. c. Dilantin should be given with food because it causes gastrointestinal distress. d. It must be given in normal saline. e. It must be filtered.