A patient has just undergone an abdominal aortic aneurysm repair. The patient is pulling at the Foley catheter, nasogastric tube, central line, and abdominal dressing and a wrist restraint is ap-plied after an order is received
Later, the patient reports tingling and numbness in the fingers and hand. Which actions should the nurse take? (Select all that apply.) a. Remove the restraint immediately.
b. Remind the patient this will decrease with time.
c. Notify the health care provider.
d. Medicate the patient for pain.
e. Stay with the patient.
A, C, E
If a patient has altered neurovascular status (tingling and numbness) remove the restraint imme-diately, stay with the patient, and notify the health care provider. Tingling and numbness will not decrease with time; it will continue to cause damage. The patient does not need pain medication; the restraint is too tight and needs to be removed.
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The father of an 11-year-old child with type 1 diabetes mellitus says that the child has frequent nightmares and wakes up in the middle of the night. What could be the cause of the nightmares?
1. The child is experiencing anxiety related to the diabetes. 2. The child might be experiencing Somogyi phenomenon, which often occurs at night. 3. The child might be experiencing dawn phenomenon with blood sugar elevations. 4. The child's nightmares have nothing to do with the diabetes.
The nurse is instructing a patient who is experiencing diarrhea associated with a microorganism not to use an antidiarrheal medication. The patient asks, "Why can't I take something to stop the diarrhea?" How should the nurse respond to this patient?
1. "Antidiarrheal medication slows down the elimination of the microorganism causing the diarrhea." 2. "Antibiotics are always used to treat the microorganisms but antibiotics may worsen diarrhea." 3. "The potassium you are taking will help to slow down the diarrhea." 4. "Your physician does not like to use antidiarrheal medications."
An instrument that is reliable for one group may not be reliable for another group
A) True B) False
A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures:
A. Near vision B. Color vision C. Distant vision D. Peripheral vision