A trauma patient is being assessed with the Trauma and Injury Severity Score (TRISS) system. What assessment data should the nurse use with this scoring system? Select all that apply.
A. Systolic blood pressure
B. Heart rate
C. Glasgow coma scale
D. Respiratory rate
E. Diastolic blood pressure
Answer: D
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A child who has symptoms of irritable mood, changes in sleep and appetite patterns, decreased self-esteem, and disengagement from family and friends lasting 3 weeks meets the criteria for which depressive disorder?
a. Major depressive disorder b. Dysthymic disorder c. Cyclothymic disorder d. Panic disorder
The nurse is performing an assessment of a client with suspected esophageal cancer. Which statement made by the client does the nurse correlate with advanced disease?
a. "I have difficulty swallowing solids." b. "I usually have a sticking feeling in my throat." c. "I have difficulty swallowing soft foods." d. "I have difficulty swallowing liquids."
The nurse understands that dilation of the pupil to permit more light to enter the eye is stimulated by the:
a. sympathetic nervous system. c. central nervous system. b. parasympathetic nervous system. d. cholinergic nervous system.
How does a nurse best begin the planning step in the nursing process?
a. Formulate and establish goals or outcomes for the client b. Collect all the data available about the client's condition c. Prioritize the steps of the nursing care to be provided d. Write down the nursing diagnosis