The client states, "I had a bad night. I didn't get any sleep." Which remark by the nurse is most therapeutic?
a. What kept you awake?
b. Why weren't you able to sleep?
c. You didn't sleep well?
d. I'm sorry; what happened?
ANS: C
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The nurse has received a child from the Emergency Department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. The nurse would question which of the following physician's order?
1. Hourly vital signs and neuro checks 2. Passive range-of-motion exercises 3. Elevate head of bed 30 degrees. 4. Oxygen at 2L nasal cannula to keep saturation above 95%
Which of the following is a common cause of postoperative hypertension?
a. Administration of morphine c. Bladder distention b. Fluid overload d. Tachycardia
The nurse is assessing a client admitted to the hospital for congestive heart failure (CHF) and notes 1+ pitting edema of the left arm, as well as bilateral 1+ pitting edema in the client's ankles
The client's history indicates that the client has had a myocardial infarction and a left mastectomy. Which is the most probable cause of the edema in the client's left arm? 1. Impaired lymphatic drainage. 2. Noncompliance with medication regimen. 3. Right-sided heart failure. 4. Excessive intake of sodium.
A school nurse has identified that there has been an increase in sexually transmitted infections (STIs) among the adolescents attending the school. Which of the following interventions should be completed by the nurse?
a. Arrange for the health department to come to the school to give information and treatment on a confidential basis b. Encourage the athletic coaches to distribute condoms in such a way that a boy can obtain them in private c. Have English teachers assign stories about the problems that result from adolescent pregnancy d. Have the bus drivers put a comic book about sexuality, STIs, and preventive measures on each seat