Which client's level of consciousness is within normal limits?
1. States name, age, and date but not location
2. Is lethargic, responds logically to questions
3. Responds verbally but words are unintelligible
4. Opens eyes spontaneously, is alert and oriented
4
4. The client who has spontaneous eye opening and is alert and oriented exhibits neurological findings that are within normal limits. The client is conscious, responds to the environment, and has congruent thought processes.
1. The client who does not know the location is disoriented to place.
2. Lethargy is not a normal finding despite correct responses.
3. Unintelligible speech is abnormal.
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A client with portal hypertension has bluish veins just under the skin of the abdomen that radiate out across the umbilicus. Which pathophysiological factors does the nurse recognize causes this condition? Select all that apply.
A) Elevated bilirubin levels B) Impaired clearance of ammonia C) Increased fluid in the abdomen D) Impaired metabolism of estrogens E) Increased abdominal pressure
The nurse is designing a study to determine why some patients with diabetes develop foot ulcers while others do not. When reviewing this research question, what should the nurse highlight as the sample population?
1. Patients with diabetes 2. Foot ulcer development 3. Patients with foot ulcers 4. Patients without foot ulcers
The nurse is preparing to administer a barbiturate. Which conditions or disorders would be a contraindication to the use of these drugs?
(Select all that apply.) a. Gout b. Pregnancy c. Epilepsy d. Severe chronic obstructive pulmonary disease e. Severe liver disease f. Diabetes mellitus
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.