The nurse is caring for a patient admitted to the intensive care unit with a subarachnoid bleed. Vital signs are as follows: blood pressure (BP) 120/74 mm Hg, pulse 70 beats/min, and respirations 16 breaths/min
Several hours later, the patient requests help to have a bowel movement. The patient refuses a bedpan and asks to use a bathroom. When told that this is not possible, the patient becomes angry and belligerent and starts yelling at the nurse. Vital signs are now BP 160/60 mm Hg, pulse 48 beats/min, and respirations 12 breaths/min. The neurosurgeon has been paged but has not yet responded. With which of the following actions should the LPN anticipate assisting the RN?
a. Waiting for the neurosurgeon to call back with orders
b. Administering an as-needed dose of a sedative that is ordered
c. Helping the patient to get up on a bedside commode
d. Paging security to restrain the patient from harming the nurse
ANS: B
Patients with subarachnoid hemorrhage are at risk for rebleeding. Straining to have a bowel movement and agitation both increase the risk of rebleed. The patient may need to be sedated until the physician can be contacted. Bringing in security will be upsetting to the patient and can also increase the risk of raising the BP and bleeding.
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. A home health nurse meets with the family of a 90-year-old woman who is living independently but needs help to remain at home. The family is arguing about who is going to provide that care or who will pay for it
The nurse's plan of care should focus on: A) Accessing who is going to be involved in the care of the patient so that assignments can be given B) Allowing the patient to negotiate the situation with her family to create trust and understanding C) Providing family access to a professional problem-solver, such as an attorney to provide legal advice to the woman D) Accessing and facilitating family member communication and design interventions that focus on coping behaviors
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Indicate whether the statement is true or false.
Select the statement that best explains the potential effect of hyperchloremia in the body.
A. The presence of high levels of chloride causes more hydrogen to be retained in the blood to help balance the excess chloride, causing the development of hyperchloremic acidosis. B. The presence of high levels of chloride causes more hydrogen to be retained in the blood to help balance the excess chloride, causing hyperchloremic alkalosis. C. The presence of high levels of chloride causes more chloride to be absorbed by the renal tubules, leaving less chloride in the extracellular fluid, thereby causing the development of acidosis. D. None of these statements are correct.
The nurse is caring for a client with a nasogastric (NG) tube after an episode of GI bleeding. Which interventions are included in the nursing care plan? (Select all that apply.)
a. Monitor and record intake and output every 8 hours. b. Monitor hemoglobin and hematocrit laboratory values. c. Ensure that suction is set on high continuous for Levin tubes. d. Measure the client's girth and/or assess for distention daily. e. Pin the tube to the client's gown, so it cannot be dislodged. f. Check vital signs and orthostatic blood pressure every 4 hours and PRN.