Noticing swelling on a patient is an example of
a. subjective data. c. objective data.
b. charting. d. nonverbal communication
c
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A pregnant woman at 30 weeks gestation is in the CCU with severe eclampsia. She is experiencing pulmonary edema, severe oliguria, and hypotension and continues to have seizures
She is endotracheally intubated, supported by a mechanical ventilator, and is receiving intravenous magnesium sulfate at 3 g/hr; the serum magnesium level is 8 mg/dL. She is beginning spontaneous early labor. What is the most important intervention? A) Administer medication to delay the onset of labor, as is preterm. B) Increase the dose of magnesium sulfate to control seizures. C) Facilitate delivery of the baby, as eclampsia is worsening. D) Administer high-dose diuretics for the pulmonary edema.
A patient is unable to recognize or name familiar objects during her assessment. You would record this response as
a. agnosia. c. constructional apraxia. b. apraxia. d. visual amnesia.
An older adult patient reports burning and itching eyes. On assessment, the nurse notes swelling of the eyelid margins bilaterally. What additional data are necessary to confirm the nurse's sus-picion of blepharitis?
a. The patient reports visual disturbances such as rainbow halos. b. The eyelids are reddened from seborrhea. c. The patient is being treated with anticoa-gulants. d. Small corneal hemorrhages are present.
A family with 4 children has just learned that their third child, age 5, has been diagnosed with ADHD. The nurse has assessed the child and the family and is planning care with them
Which of the following statements by the mother leads the nurse to a diagnosis of compromised family coping? 1. "We need to alert the teachers at school so they will know how to give Tommy's medication.". 2. "I'm not sure if we should let Tommy act in the school play.". 3. "Will he have to be put in an institution?" 4. "I don't know how to tell the rest of the family or how we will manage the other children.".