A nurse has assessed the patient with a left-sided head injury and records this information: decreasing level of consciousness; slow pupillary response on the right side; blood pressure, 167/80 mm Hg; previous blood pressure, 160/72 mm Hg; and
gradually increasing respiratory and pulse rates. The nurse is aware that these assessments are indicators of _____. Fill in the blank(s) with correct word
increasing intracranial pressure (ICP)
All of the listed assessments indicate ICP.
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The nurse prepares the medication ordered for the client. The nurse asks the nurse assistant to give the medication when the client receives breakfast and to report on the task at its completion. The nurse assistant agrees
Which component of the steps of delegation was violated by this request? 1. Defining the task 2. Deciding on the delegate 3. Determining the task 4. Reaching agreement
An older adult with heart failure and mild dementia states the intent to refuse low sodium diet and diuretics, stating: "It's important to me to live free, without restrictions on what I eat." The family is supportive. Which action, by the nurse
should be done first? A) Assure that the client understands the consequences of this decision. B) Discuss this decision with the older adult's family to plan for the future. C) Document the client's wishes in the plan of care. D) Notify the primary health care provider of the client's wishes.
During patient education, the nurse discusses the major side effects of thiazide diuretics, because the patient has just begun therapy. The nurse should review the laboratory results for the patient and should be concerned about a finding of a
a. blood sugar level of 80. b. potassium level of 3. c. blood pressure of 106/48. d. potassium level of 5.7.
Patients taking riluzole for amyotrophic lateral sclerosis should be instructed to take the medication:
1. before bed. 2. with meals. 3. 1 hour before or 2 hours after meals. 4. every 4 hours with water.