A client with dysfunctional labor patterns has a nursing diagnosis of "Acute pain maternal, related to uterine irritability and prolonged labor." Which of the following would the nurse use as evidence to support this diagnosis?
a. Non-reassuring fetal tracing inclusive of severe variable decelerations; late decelerations
b. Maternal fever of 100.4°F or 38°C, maternal tachycardia, fetal tachycardia, or a combination of these
c. Client questions and an inability to cooperate with requested interventions
d. Frequent or persistent maternal requests for pain relief, frequent uterine contractions, poor uterine resting tone, and failure of the cervix to dilate 1 to 2 cm per hour on cervical assessment
D
The most appropriate evidence to support the diagnosis of acute pain would include frequent or persistent maternal requests for pain relief, frequent uterine contractions, poor uterine resting tone, and failure of the cervix to dilate 1 to 2 cm per hour on cervical assessment
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A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask when determining the possible severity of the burn injury?
Select all that apply. 1. What type of current was involved? 2. How long was the patient in contact with the current? 3. How much voltage was involved? 4. Where was the patient when the burn occurred? 5. What was the point of contact with the current?
A patient in the emergency room has status epilepticus. The nurse should anticipate administration of
a. diazepam (Valium). b. buspirone (BuSpar). c. clorazepate (Tranxene). d. chlordiazepoxide (Librium).
A patient has been taking lithium for 5 days. The nurse notes his gait is a little unsteady with a walker, and he complains of thirst and insomnia. Which finding is most important for the nurse to report?
a. Manic behavior b. Unsteady gait c. Thirst d. Insomnia