The nurse is caring for a client who was discovering unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled
Which instructions have been compiled for the spouse? A) Tylenol may be administered for aches.
B) Observe for any signs of behavioral changes.
C) A light meal may be eaten if desired.
D) Follow up with regular physician is encouraged.
B
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All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve.
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A patient is receiving aldesleukin, or interleukin-2 (IL-2), as an immunosuppressant. Which of the following complications may develop during the first 12 hours after the start of the infusion?
a. Capillary leak syndrome b. Bradycardia c. Respiratory depression d. Low core temperature
The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin. What orders does the nurse anticipate from the health care provider? (Select all that apply.)
a. Laboratory draw for activated partial thromboplastin time (aPTT) b. Administer vitamin K c. Laboratory draw for prothrombin time (PT)/international normalized ratio (INR) d. Administer protamine sulfate e. Administer enoxaparin (Lovenox)
When asked about the use of herbal therapy for children, the nurse appropriately replies:
a. "Adverse effects are seen less commonly in children." b. "Parents should not assume that ‘natural' means ‘safe.'" c. "The use of herbal therapy for children has declined recently." d. "Extensive studies have documented toxic effects of herbs and plants in children."
During the initial inspection of the female genitalia, the nurse recognizes which finding as normal?
a. The labia minora are hair-covered and lying within the labia majora. b. The cervical os in the multiparous woman has the shape of a small circle. c. The vaginal vestibule lies between the labia minora and contains the urinary meatus. d. The openings of Skene's and Bartholin's glands are visible posteriorly.