A client who was admitted 2 days ago for assessment after a fall in his home has become increasingly irritable and now says there are bugs on his bed. He is diaphoretic and has a blood pressure of mm Hg. The nurse assesses
a. alcohol-induced psychosis.
b. delirium tremens.
c. neurologic injury related to the fall.
d. post-traumatic stress reaction.
B
During the 2 days after cessation of alcohol use, clients may experience delirium tremens (DTs), as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallu-cinations.
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The nurse caring for a patient with an endotracheal tube measures the cuff pressure on the tube and recognizes that a normal cuff pressure ranges between:
A) 10 to 15 cm H20 B) 15 to 20 cm H20 C) 20 to 25 cm H20 D) 25 to 30 cm H20
A 5-year-old child is brought to the emergency department with copious drooling and a croaking sound on inspiration. Her mother states that the child is very agitated and only wants to sit upright
What should be the nurse's first action in this situation? a. Prepare intubation equipment and call the physician. b. Examine the child's oropharynx and call the physician. c. Obtain a throat culture for respiratory syncytial virus (RSV). d. Obtain vital signs and listen to breath sounds.
The nurse performs digital removal of a fecal impaction for the client with atrial fibrillation and heart failure. Which is the most serious unexpected client assessment the nurse assesses during the procedure?
1. Rectal bleeding 2. Perianal redness 3. Liquid stool leakage 4. Abdominal cramping
Important techniques in performing the rectal examination include which of the following?
A) Lubrication B) Waiting for the sphincter to relax C) Explaining what the patient should expect with each step before it occurs D) All of the above