Which of the following phases of the nursing process encompasses the establishment of a baseline to formulate the care plan?
A) Assessment
B) Nursing diagnosis
C) Planning
D) Implementation
A
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A young child admitted to the Pediatric unit has fever, irritability, and vomiting. The physician suspects bacterial meningitis. The nurse would expect the cerebrospinal fluid (CSF) to show:
1. Protein count of 50 mg/dL. 2. Increased glucose level. 3. Decreased glucose level. 4. Negative Gram stain.
The nurse is caring for a client is scheduled for chemotherapy followed by autologous stem cell transplant. Which of the following statements by the client indicates a need for further teaching?
A) "I hope they find a bone marrow donor who matches." B) "The doctor will remove cells from my bone marrow before beginning chemotherapy." C) "I will receive chemotherapy until most of the cancer is gone, and then I will get my own stem cells back." D) "I will need to be in protective isolation for up to 3 months after treatment."
A patient with a suspected spinal cord tumor is undergoing diagnostic testing for loss of motor function and sensation possibly related to compression of the spinal cord
In preparation for diagnostic studies, the nurse will inform the patient that the most commonly used study to diagnose spinal cord compression from a tumor is a(n): A) X-ray B) Ultrasound C) CT scan D) MRI scan
If a patient has taken excessive doses of antihistamines, the nurse would expect which findings? You may select more than one answer
a. Dilated pupils b. Urinary frequency c. Pallor d. Drooling e. Tachycardia