The nurse is admitting a client who has had a severe head injury. The nurse expects that signs of worsening cerebral edema will occur over which of the following?
1. 24 hours
2. 36 hours
3. 48 hours
4. 72 hours
4. 72 hours
Rationale:
Cerebral edema increases for 72 hours after injury.
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A depressed client who is taking a tricyclic antidepressant tells the nurse "I don't think I can keep
taking these pills. They make me very dizzy, especially when I stand up.". The nurse should a. explain how to mange hypotension and reassure that side effects go away after several weeks. b. tell the client that the side effects are a minor inconvenience compared with feelings of depression. c. withhold the drug and have the physician examine the client. d. perform a mental status examination on the client.
A nursing care plan is:
1. followed exactly once adopted by interdisciplinary care team. 2. standardized to prevent duplication of efforts. 3. kept separate from the patient's record. 4. frequently modified to reflect the client's changing status.
Which finding in the client with HIV disease who is receiving highly active antiretroviral therapy (HAART) indicates that the treatment is effective?
A. Increased CD4+ cells. B. Decreased CD4+ cells. C. Increased CD8+ cells. D. Decreased CD8+ cells.
The nurse is assessing a patient whose body mass index is within the overweight category. When identifying nursing diagnoses for this patient, which of the following should be included?
1. altered health maintenance 2. imbalanced nutrition: more than body requirements 3. risk for injury 4. risk for exercise intolerance