A patient is admitted to the emergency department after ingesting a large amount of an unknown substance while at a beach party. The nurse finds delirium, dry and flushed skin, dilated pupils, fever, decreased bowel sounds, and tachycardia
Urinary catheter insertion shows urinary retention. What ingested substance does the nurse most suspect?
A) Malathion
B) Jimsonweed
C) Opiates
D) Cocaine
B
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The nurse caring for a 90-year-old patient with a closed head injury would immediately report:
1. blood pressure change from 147/72 to 176/70. 2. respiration rate increase from 14 to 18. 3. slow pupillary reaction bilaterally. 4. temperature decrease from 100.2 to 97.6.
You are a maternal-newborn nurse caring for a mother who just delivered a baby born with Down syndrome. What nursing diagnosis is the most essential in caring for the mother of this infant?
a. Disturbed body image b. Interrupted family processes c. Anxiety d. Risk for injury
The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the patterns of sole creases?
A) Creases on two thirds of the foot B) Heel creases but no anterior creases C) Longitudinal but no horizontal creases D) Creases covering one fourth of the foot
Parents are concerned that their 6-year-old son continues to occasionally wet the bed. What does the nurse explain?
a. This is likely because of increased stress at home. b. Enuresis usually ceases between 6 and 8 years of age. c. Drug therapy will be prescribed to treat the enuresis. d. Testing will be necessary to determine what type of kidney problem exists.