The nurse is preparing a surgical client for a physical examination. The nurse has several questions to ask the client
The nurse uses the COLDSPA mnemonic to remember to include all the essential information during the nursing data gathering and assessment. What information is the nurse seeking when asking the client: "How bad is it?" and "Can you rate it on a scale of 1 to 10?"? A) Onset
B) Location
C) Duration
D) Severity
D
Feedback:
ONSET: When did it begin? LOCATION: Where is it? Can you identify a specific location? Does it radiate? DURATION: How long does it last? Does it recur? SEVERITY: How bad is it? Can you rate it on a scale of 1 to 10?
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Which client situation presents the greatest risk for the occurrence of hypotonic dysfunc-tion during labor?
a. A primigravida who is 17 years old b. A 22-year-old multiparous woman with ruptured membranes c. A multiparous woman at 39 weeks of gestation who is expecting twins d. A primigravida who has requested no analgesia during her labor
The anatomy and physiology instructor is talking with the students about circulating plasma proteins called complement. Complement has three major physiologic functions, one of which is what?
A) Protecting the body against viral infection B) Marking the parameters of the immune response C) Bridging natural and acquired immunity D) Collecting immune complexes during inflammation
The client has been ordered treatment with Aralen. The nurse notes that the client's blood pressure has decreased from 130/80 to 104/60. What is the nurse's highest priority action?
a. Recognize that this is an expected side effect of the medication and monitor the client. b. Call the physician; the client is experiencing an adverse reaction to the medication. c. Recognize that this is a reaction to the dosage of the medication; call the pharmacist. d. Call the physician; client is experiencing a life-threatening reaction to the medication.
A patient newly diagnosed with thrombocytopenia is admitted to your unit. After the admission assessment, the patient asks you to explain the disease to her. What would you explain to the patient about this condition?
A) There could be an attack on the platelets by the antibodies B) There could be decreased production of platelets C) There could be elevated platelet production. D) There could be decreased white blood cell production.