A client has been declared brain dead following a motor vehicle accident. What assessment data would the nurse anticipate?
a. no ocular movement
b. breathing drive triggered only by respirator
c. positive corneal response
d. sluggish pupillary response
Answer: a. no ocular movement
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While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
a. "Grade 3 phlebitis at IV site" b. "Infection at IV site" c. "Thrombosed area at IV site" d. "Infiltration at IV site"
A 40-year-old who lives with parents and works at an unchallenging job says, "I'm as happy as anyone else, even though I don't socialize much outside of work
My work is routine, but when new things come up, my boss explains things a few times to make sure I catch on. At home, my parents make decisions for me, and I go along with their ideas." The nurse should identify interventions to improve this patient's: a. self-concept. b. overall happiness. c. appraisal of reality. d. control over behavior.
A child is admitted with acute glomerulonephritis. The nurse would expect the urinalysis during this acute phase to show which results?
1. Bacteriuria, hematuria 2. Hematuria, proteinuria 3. Bacteriuria, increased specific gravity 4. Proteinuria, decreased specific gravity
Suicide is a high risk among clients with dual diagnoses. Which of these dual diagnoses, when linked with suicidal intention, is considered part of the "deadly triangle" in the elderly?
a. alcohol abuse and panic disorder b. schizophrenia and drug abuse c. depression and alcohol abuse d. bipolar disorder and drug abuse