A young woman calls the clinic to report a fever and a funny rash with peeling skin on the palms of her hands and the soles of her feet. Which action by the nurse is most appropriate?
a. Make an appointment for her to be seen the next day at the clinic.
b. Instruct her to take warm baths with oat-meal added to the water.
c. Tell her to go to the emergency depart-ment immediately.
d. Have her take acetaminophen (Tylenol) every 4 hours and drink fluids.
C
These signs are consistent with toxic shock syndrome, a potentially life-threatening bacterial in-fection often associated with tampon use in menstruating women. The client requires immediate medical attention and should go to the nearest emergency department. Waiting until the next day, taking warm baths, and using symptom control measures such as Tylenol and fluids only lead to delay in obtaining necessary care.
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A nurse tearfully confides to the head nurse that being assigned to care for eight patients is stressful and overwhelming. The head nurse assesses the use of a healthy coping mechanism observing the nurse:
a. writing down long lists of needed interventions before starting the day's work. b. delegating appropriate care assignments to nursing assistants. c. asking a co-worker to take one of her patients. d. asking for the day off.
When a pregnant diabetic experiences hypoglycemia while hospitalized, the nurse should have the client:
a. eat six saltine crackers or drink 8 oz of milk. b. drink 8 oz of orange juice with 2 teaspoons of sugar added. c. drink 4 oz of orange juice followed by 8 oz of milk. d. eat a candy bar.
A hospitalized toddler, previously bowel trained, has been having incontinent stools. What would the nurse tell the parents about this behavior?
A) "When he does this, scold him and he will quit." B) "I don't understand why this child is losing control." C) "This is normal when a child this age is hospitalized." D) "I will have to call the doctor and report this behavior."
A 15-month-old child from Pennsylvania was brought to the ER with symptomology that in-cludes fever, seizure activity, cranial palsies, and paralysis. Which form of encephalitis is best supported by the available assessment data?
a. Eastern equine encephalitis b. Venezuelan encephalitis c. St. Louis encephalitis d. West Nile encephalitis