The nurse has documented that the client has orthostatic hypotension. Which of the following assessment findings would support this assessment? Select all that apply
1. Decrease in blood pressure when moving from supine to standing
2. Decrease in heart rate when moving from supine to sitting
3. Pale color in the legs when lying in bed
4. Complaints of dizziness when first sitting up
5. Increased respiratory rate on exertion
1; 4
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The nurse is performing a focused interview with an adult male client who recently experienced a myocardial infarction. The nurse requests information about how he felt during the time of the myocardial infarction
Which client statement would be unexpected? 1. "I couldn't catch my breath." 2. "My chest didn't actually ever hurt." 3. "My wife said I looked like someone poured water all over me." 4. "I got so sick to my stomach."
A patient presents to the clinic with a sore throat and sinus pain, but the nurse notices several bruises of different ages, including some on her face. When asked, the patient states she fell down the stairs last week
Which action by the nurse is best? a. Ask the patient outright whether she is being abused by someone. b. Call local law enforcement to come and take a crime report. c. Document the injuries but do not question the patient about it. d. Explain that these injuries do not seem consistent with a fall.
A patient with severe spasticity sees his physician. The physician orders dantrolene. In what circumstances is the drug dantrolene contraindicated?
A) Spasticity that contributes to upright position B) Spasticity that involves both legs C) Spasticity that involves the arm and the leg on the same side D) Spasticity that contributes to mobility
A client has developed distributive shock as a result of a brain injury. During the initial assessment, the nurse would expect to see which of the following vital sign results?
a. Heart rate 60 bpm b. Blood pressure 92/58 mmHg c. Temperature 102F d. Respiratory rate 18/minute