The nurse suspects that patient who received intramuscular penicillin for treatment of secondary syphilis is developing the Jarisch-Herxheimer reaction. What information did the nurse use to make this clinical determination?
Select all that apply.
1. new onset of fever
2. heart rate 112 beats per minute
3. sudden severe abdominal cramping
4. complaints of musculoskeletal pain
5. administration of medication 16 hours ago
Correct Answer: 1, 2, 4, 5
Manifestations of the Jarisch-Herxheimer reaction include fever, tachycardia, and musculoskeletal pain. The Jarisch-Herxheimer reaction generally begins within 24 hours of treatment. Sudden severe abdominal cramping is not a manifestation of this reaction.
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The nurse anticipates that the normal aging process of losing neurons and shrinkage of brain size will result in which assessment findings in older adults? (Select all that apply.)
a. Confusion b. Slower response times c. Depression d. Deficiencies in short-term memory
The nurse is caring for a patient who has had a nasogastric tube in place for 2 days. The tube is draining green aspirate. What does this color of aspirate indicate?
A) The tube is in the pleural space. B) The tube is in the intestine. C) The tube is in the stomach. D) The tube is in the esophagus.
The nurse is caring for a pregnant woman who admits to using Ecstasy on a regular basis. The client states, "Everybody knows that alcohol is bad during pregnancy, but what's the big deal about Ecstasy?" Which response by the nurse is appropriate
A) "Ecstasy use leads to deficiencies of thiamine and folic acid, which help the baby develop." B) "Ecstasy use produces babies with small heads, short bodies, and brain function alterations." C) "Ecstasy use results in intrauterine growth restriction and meconium aspiration." D) "Ecstasy use has been associated with long-term impaired memory and learning in the child."
The function of the interdisciplinary health care team is to:
a. assess, maintain, and evaluate the abilities of clients upon completion of therapy b. provide care and evaluate the abilities of clients in need of functional therapy c. evaluate the effectiveness of treatment of clients in functional therapy d. assess and provide care for the clients in need of functional therapy