A patient with head trauma is being monitored with an intraventricular catheter device (IVC). The patient's intracranial pressure (ICP) had been staying around 20 mm Hg, but moments ago, it spiked up to 55 mm Hg
What complication related to the monitoring device itself would best explain this dramatic increase in ICP?
A) Infection at the catheter access site
B) Obstruction of the catheter
C) Hemorrhage
D) Misplacement of catheter
B
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Which assessment finding should the nurse expect to observe on an immobilized patient?
a. Increased serum glucose levels b. Decreased urine excretion c. Positive nitrogen balance d. Increased serum potassium levels
A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse. As the student nurse charts the interaction, which statement is the best way to document what happened?
a. Appears to be in pain as evidenced by grouchy behavior b. Behavior is inappropriate, requests registered nurse do the assessment c. States, "I want a registered nurse to do my assessment" d. Is grumpy, registered nurse notified
The nurse is caring for a client who had right total knee replacement surgery 3 days ago. During the assessment, the nurse notes that the client's right lower leg is twice the size of the left. What is the nurse's priority intervention?
a. Elevate the client's right leg. b. Apply antiembolism stockings. c. Assess the client's respiratory status. d. Check the client's pedal pulses.
Mild anxiety affects the communication process by
a. severely restricting the perceptual field c. broadening the per-ceptual field b. blocking perception d. distorting the per-ceptual field