The nurse is auscultating the temporal artery and hears a soft blowing sound. Which term should the nurse use to document the findings?
A. Murmur.
B. Bruit.
C. Stenosis.
D. Occlusion.
Answer: B
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It will be most important for the nurse to monitor nevirapine therapy for a male patient during the first few months of therapy in order to
A) determine CD4+ T-cell counts. B) assess for potentially life-threatening hepatotoxicity or skin reactions. C) assess the drug serum level. D) evaluate for thrombocytopenia.
In the emergency department, a patient's vital signs are: BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow
The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic overdose. Select the priority outcome. a. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. b. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. c. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields. d. The patient will demonstrate effective coping skills within 1 week of hospitalization. e. The patient will identify community resources for treatment of substance abuse.
During the focused interview, a male client describes his erection and ejaculate in terms that are less than professional. The nurse would correctly do which of the following?
1. Ask the client to refrain from using the terms. 2. Ask the client to define the terms. 3. Document the client's responses in the terms used. 4. Find another nurse to complete the assessment.
The telephone triage nurse at a pediatric clinic knows each call is important. Which call would require extra attentiveness from the registered nurse because of an increased risk of mortality?
1. A 3-week-old infant born at 35 weeks gestation with gastroenteritis 2. A term 2-week-old infant of American Indian descent with an upper respiratory infection 3. A post term 4-week-old infant non-Hispanic black descent with moderate emesis after feeding 4. A 1-week-old infant born at 40 weeks gestation with symptoms of colic