The nurse receives a patient from the emergency department following a closed head injury
After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician order should the nurse institute first? a. Mannitol 1 g intravenous
b. Portable chest x-ray
c. Seizure precautions
d. Ancef 1 g intravenous
A
The patient's GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario.
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Once the acute feelings of illness are resolved, what is an appropriate intervention when treating a client with a psychosocial problem?
a. Avoid expression of feelings as this will provide a relapse of acute symptoms. b. Minimize secondary gains. c. Convey an attitude that such behavior is not acceptable. d. Assist the client to limit social network to avoid additional stress.
The nurse is providing care for a client with terminal breast cancer. The client's children ask if their mother will exhibit any signs and symptoms prior to death
When responding to the family, which statements regarding the expected clinical manifestations of impending death will the nurse include? Select all that apply. 1. "Your mother's jaw may sag." 2. "Your mother may have difficulty speaking." 3. "Your mother may have trouble swallowing." 4. "Your mother may feel hot to the touch." 5. "Your mother may begin to breathe only through her nose."
The 75-year-old patient is preparing for discharge and tells the case manager, "I don't know what I am going to do when I get home. I cannot afford the medications the doctor has ordered for me." What is the case manager's most appropriate response?
a. "We can have a social worker see you when you get home." b. "Medications are expensive, but you will need to take them." c. "I can speak with your doctor about discontinuing some of the medications." d. "The home health nurse will address this when she sees you."
A nurse is caring for a client with a swallowing disorder. Which therapeutic nursing intervention should be considered when feeding this client?
A) Separate the food according to the water content. B) Encourage the client to swallow each portion of food. C) Tell the client to take a small sip of water after each portion. D) Talk with the primary care provider about an order for a semiliquid diet.