The charge nurse on a busy high acuity care unit is reviewing the plan of care for 4 patients
When planning interventions and room assignments, which of the following patient will be at the highest risk for experiencing sensory perceptual alterations (SPAs)? 1. 22-year-old male patient who has been hospitalized for complications related to diabetes
2. 41-year-old female patient admitted to rule out a myocardial infarction
3. 79-year-old female patient diagnosed with end stage renal failure
4. 25-year-old male patient diagnosed with new onset diabetes
3
Rationale: Patients who are very young, very old, and postoperative or unresponsive are at the greatest risk for experiencing sensory perceptual alterations (SPAs). The 79-year-old patient is at the greatest risk as a result of age and diagnosis. The remaining patients are at risk if they are on the high acuity care unit but are not as compromised as the elderly woman.
You might also like to view...
The nurse teaches the client how to self-administer insulin, and determines further teaching is needed when the client states:
1. "I should rotate the site I use for injections." 2. "I should draw back on the plunger before injecting the insulin." 3. "I will clean the site using an antiseptic wipe, and rub in a circle." 4. "I should never inject insulin in an area with a bruise."
A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this patient's immediate care? Select all that apply
A) Administering diuretics to prevent fluid overload B) Administering beta blockers to reduce heart rate C) Administering insulin to reduce blood glucose levels D) Applying interventions to reduce the patient's temperature E) Administering corticosteroids
Even though the nurses in a patient care area have been asked to collect data while conducting patient care, several nurses do the data collection only if time is available
Which research problem criteria does the inconsistent collection of data exemplify? 1. Feasible to address 2. Researchable 3. Of interest to the researcher 4. Significant to nursing
A client has preeclampsia. She is 36 weeks' pregnant, and comes to the high-risk screening center for a contraction stress test. The nurse should explain to the client that the contraction stress test is being done to determine:
1. What affect her hypertension has had on the fetus. 2. If the fetus will be able to tolerate labor. 3. If fetal movement increases with contractions. 4. What effect contractions will have on her blood pressure.