The nurse is caring for a patient with increased intracranial pressure and confusion. Which of the following interventions would be appropriate for this patient?
1. keep the patient's room dark at night
2. encourage the family to visit whenever possible
3. keep noise to a minimum
4. keep one side rail down at all times
3
Rationale: Nursing interventions for a patient with increased intracranial pressure and confusion are focused on protecting the patient from injury, reorienting, and creating a calm, safe environment. Noise should be kept to a minimum, and the number of visitors at one time is limited. A dim light should also be kept on at night to control confusion. Because the patient may attempt to get out of bed, the bed should be kept in a low position for safety with all side rails in the raised position.
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The nurse, caring for a patient diagnosed with lung cancer, determines that the patient might be experiencing superior vena cava syndrome when which finding is assessed?
1. Face and neck swelling 2. Hourly urine outputs 250 to 500 mL 3. Calcium level of 14.0 mg/dL 4. Flat jugular veins
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What will be an ideal response?
When completing a community assessment, the community health nurse will take several aspects into account. What is the first stage of this assessment that the nurse will complete?
1. Learn about the people in the community. 2. Understand the major illnesses present in the community. 3. Identify the boundaries of the community. 4. Make sure resources are available in the community.