The staff educator is precepting a nurse new to the unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock
What would the staff educator and the new nurse monitor this patient for?
A) Increased cardiac markers
B) Hypotension
C) Tachycardia
D) Excessive sweating
Ans: B
Feedback: Manifestations of neurogenic shock include decreased blood pressure and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Patients do not perspire on the paralyzed portions of their body due to blockage of sympathetic activity.
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You are an emergency department nurse working triage during a disaster. Why should you tag a victim after assessment in a disaster situation?
A) To know the victim's name B) The tag states the triage category of the victim. C) Someone else does not duplicate the assessment. D) Call for immediate hospitalization.
When the nurse formulates nursing diagnoses, it is necessary to be specific in describing dysfunctional behaviors so as to
a. select appropriate desirable behaviors for outcome criteria. b. analyze how the patient was feeling at the time of assessment. c. explore the context that precipitated the exacerbation of the illness. d. determine how the illness relates to the patient's total life experience.
Nurses understand there are inherent risks in making decisions. These are all risks except:
a. there will always be more information to gather and analyze. b. information must be researched and complete. c. time constraints and priority setting. d. information is never complete.
A client has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this client? (Select all that apply.)
a. Be careful not to drop the hearing aid when handling. b. Soak the hearing aid in hot water for 20 minutes. c. Turn the hearing aid off when the client goes to bed. d. Use a toothpick to clean debris from the device. e. Wash the device with soap and a small amount of warm water.