A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate
a. Anxiety due to hospitalization
b. Worsening disease and impending convulsion
c. Effects of magnesium sulfate
d. Gastrointestinal upset
B
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A These are danger signs and should be treated.
B Headache and visual disturbances are due to increased cerebral edema.
Epigastric pain indicates distention of the hepatic capsules and often warns that a
convulsion is imminent.
C She has not been started on magnesium sulfate as a treatment yet. Also, these are
not expected effects of the medication.
D These are danger signs showing increased cerebral edema and impending
convulsion.
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While assessing an unconscious patient's neurologic status, the nurse applies pain by pinching the sternocleidomastoid muscle. Which statement by the nurse indicates an understanding of the use of this technique?
1. "Pain will make abnormal motor responses observable.". 2. "An unconscious patient's pain threshold is abnormally high.". 3. "Response to pain is an indicator of cognitive function.". 4. "The patient is most likely to respond to pain at that site.".
A patient has been admitted with a lower leg ulcer. Which findings would suggest to the nurse that care specific to a venous ulcer should be planned? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. The area around the ulcer is crusted and edematous. 2. There is copious drainage from the wound. 3. The ulcer area has a "punched-out" appearance with defined margins. 4. The area around the wound is spongy. 5. The patient reports working in an occupation that requires lots of sitting.
Nursing situations and medical case presentations are synonymous
Indicate whether this statement is true or false.
The nurse should plan which interventions when caring for a child with a visual impairment? Select all that apply
a. Touch the child upon entering the room before speaking. b. Keep items in the room in the same location. c. Describe the placement of the eating utensils on the meal tray. d. Use color examples to describe something to a child who has been blind since birth. e. Identify noises for the child.