During assessment of the patient diagnosed with systemic lupus erythematosus (SLE), which signs and symptoms would the nurse expect to find? (Select all that apply.)
a. Hair loss
b. Enlarged cervical lymph nodes
c. Mouth sores
d. Fatigue
e. Rashes
A, C, D, E
The patient with SLE does not typically have enlarged lymph nodes. Hair loss, mouth sores, fa-tigue, and rashes are just a few of the symptoms present in a patient with SLE.
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A patient with severe and refractory elevated intracranial pressure (ICP) has been in an induced barbiturate coma for 48 hours
Over the first 24 hours, the patient's ICP decreased from 30 to 14 mm Hg and her systolic blood pressure decreased from 130 to 80 mm Hg. These changes were sustained in the second 24 hours. The nurse recognizes that which of the following is the appropriate intervention for this patient? A) Administer IV solution. B) Discontinue barbiturate therapy. C) Initiate hypothermia therapy. D) Administer a sedative.
A client comes to the outpatient mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril)
The nurse reviews information about clozapine with the client. Which client statement indicates an accurate understanding of the nurse's teaching about this medication? A. "I don't need to see my doctor for a new prescription when this runs out." B. "I need to keep my appointment this week for a blood test to monitor my white blood cells." C. "I can have a martini with this medication." D. "I don't need to come into the clinic for a few months if I don't have side effects"
You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with the following report
Dr. Smith, I'm calling about Mrs. P., your 65-year-old patient in CCU 10 . Her urine output for the past 2 hours totaled only 40 mL. She arrived from surgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and her blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusion of normal saline at 100 mL per hour. Her right atrial pressure through the subclavian central line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider increasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient's history and vital signs is: a. Situation b. Background c. Assessment d. Recommendation
The nurse is instructing a patient with a compromised immune status on the signs and symptoms of infections. What should be included in these instructions?
1. Increased sputum production 2. Cloudy urine 3. Irritated oral mucosa 4. Purulent wound drainage