The client has just received news of the death of a relative. Over the next few hours, what physiologic response would the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event?
A)
A more bounding pulse
B)
A drop in blood pressure from 130/80 to 120/75
C)
Some decrease in oxygen saturation
D)
A slight increase in urine output
A
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Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:
a. documents facts. b. documents how he/she feels about the care being provided. c. documents in a "block" fashion once per shift. d. double documents as often as possible in order to not miss anything.
The nurse uses his hands to direct energy fields surrounding the patient's body. After this intervention, the patient states that his pain has lessened. How should the nurse document the intervention?
1) Tactile distraction was performed and appeared effective in reducing pain. 2) Guided imagery was effective to relax the patient and reduce the pain. 3) Therapeutic touch was performed; patient verbalized lessening of pain after treatment. 4) Sequential muscle relaxation was performed; patient states pain is less.
Glucocorticoids, mineralcorticoids, and sex steroids are secreted by the:
1. Thyroid gland. 2. Adrenal cortex. 3. Anterior pituitary gland. 4. Parathyroid gland.
A mother confides to the nurse that her live-in boyfriend knocked down her 2-year-old child because he was crying too much. She begs the nurse not to tell anyone because her boyfriend has agreed to take anger management classes
Which of the following actions should be taken by the nurse? a. Abide by the mother's wishes because this information was provided in confidence. b. Arrange for counseling for the boyfriend at the earliest possible availability. c. Encourage the mother to take the child and find alternate housing right away. d. Report the incident to child protective services or other appropriate legal authority.