A nurse is at the beach with friends when one of them begins to complain about dizziness and fatigue. It is a particularly hot day in the middle of a heat wave. How should the nurse react?
A. Call an ambulance.
B. Tell her to close her eyes and rest.
C. Give her some cool water.
D. Leave the beach with the friend and have her sit in an air-conditioned car while drinking an electrolyte replacement drink.
ANS: D
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A child, aged 10 years, is referred to the mental health clinic by the school psychologist. The child
tells the advanced practice nurse that she wants to die "because no one likes me.". She adds that "the other girls laugh at me.". She is unable to pinpoint a cause for the behavior of the other girls and does not think she can ever change their feelings about her. When she is asked if she has decided on a plan for taking her life, she states she will jump from the bridge over the river near her home some night after the family is asleep. She believes this will accomplish her goal because she saw her father throw kittens off the bridge and knows they died in the water because, like her, they couldn't swim. The nurse should make the assessment that suicide risk is a. nonexistent. b. low. c. moderate. d. high.
The neural processes of encoding and processing noxious stimuli necessary but not sufficient for pain is known as
a. perception. b. nociception. c. transduction. d. transmission.
The nurse who is to administer 2.5 mL of intramuscular pain medication to an adult client notes that the previous injection was administered in the right ventrogluteal site. In which site should the nurse plan to administer this injection?
A) The rectus femoris B) The same site C) The deltoid D) The left ventrogluteal
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 intoxication. Select the priority outcome.
a. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. 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. c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.