A factor that can cause increased intracranial pressure is
A) hyperkalemia.
B) hypoxia.
C) hypocapnia.
D) hyperoxemia.
B
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A patient in diabetic ketoacidosis is very lethargic and has a "funny" odor to his breath. The nurse would suspect this to be a result of
a. alcohol intoxication. c. hyperphosphatemia. b. hyperglycemia. d. acetone.
The nurse is preparing to auscultate the apex of the client's right lung. Which anatomical location should the nurse place the stethoscope?
A. Intercostal space sixth rib near the sternum. B. Below the scapula. C. Near the right clavicle. D. Intercostal space fourth rib near the axillary line.
The client has smoked a pack of cigarettes per day for 20 years. The client also takes oral contraceptives. In implementing a teaching plan, what is the most important information for the nurse to include?
1. "You are at a greater risk for emphysema than are nonsmokers." 2. "You are at a greater risk for developing diabetes than are smokers who do not use birth control pills." 3. "You are at a greater risk for a heart attack than are nonsmokers." 4. "The nicotine will decrease the effectiveness of your birth control pills."
What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs