The nurse is working in the emergency department and is assessing a client who states, "I woke up with this nose bleed and it hasn't stopped bleeding for 3 hours. I take blood thinners and now I am feeling woozy." Which part of this statement is concerning and needs immediate attention?

a. "I take blood thinners"
b. "It hasn't stopped bleeding for 3 hours"
c. "I woke up with this nose bleed"
d. "I am feeling woozy"


d. "I am feeling woozy"
rationale: Feeling woozy means the client is now symptomatic after blood loss. The client could potentially be shunting blood to vital organs. The nurse should ensure the client is laying down and get an EKG (ECG) to make sure the heart has a normal rhythm.

Nursing

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When prioritizing a patient's care plan based on Maslow's Hierarchy of needs, the nurse's first priority would be:

A) Allowing the family to see a newly admitted patient B) Ambulating the patient in the hallway C) Administering pain medication D) Teaching the patient to self-administer insulin

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During a physical assessment, the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. What should the nurse document that the patient is experiencing?

a. Dyspnea b. Cyanosis c. Coughing d. Ecchymosis

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According to Reichard, Livson, and Peterson, a client is classified as an "armored man." Which personality description led to this classification?

1. Rigid and stable, presenting a strong silent front 2. Passive-dependent individuals who lean on others for support 3. Aggressiveness is common, as is suspicion of others 4. Animosity is turned inward on themselves

Nursing

What is the most likely cause of croup?

a. Bacteria b. Acute hyperventilation c. Allergy d. Viral infection

Nursing