The nurse admits into the labor area a patient who is in preterm labor. The assessment finding that would constitute a diagnosis of preterm labor is:
1. Cervical effacement of 30% or more.
2. Cervical change of 0.5 cm per hour.
3. Two contractions in 30 minutes.
4. Eight contractions in 1 hour.
4
Rationale 1: Cervical effacement of 80% or more would define preterm labor.
Rationale 2: A cervical change of at least 1 cm per hour would define preterm labor.
Rationale 3: Four contractions in 20 minutes would define preterm labor.
Rationale 4: Eight contractions in 1 hour does define a diagnosis of preterm labor.
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A patient standing in the dining room screams, "You are going to kill me!" He is very agitated and seems extremely frightened. He is mumbling to himself, and his eyes are darting as if tracking an unseen person
He then says repeatedly, "No! I can't! No!" Put the nursing interventions in the order they should be undertaken. A. Send other staff to report the situation and obtain PRN medication. B. Assure the patient that staff will make sure that everyone stays safe. C. Clear the dining room of other patients and unnecessary personnel. D. Explain that the medication will stop the voices, then administer it.
A client has a serum creatinine level of 2.5 mg/dL, a serum potassium level of 6 mmol/L, an arterial pH of 7.32, and a urine output of 250 mL/day. Which phase of acute kidney failure is the client experiencing?
a. Intrarenal b. Nonoliguric c. Oliguric d. Postrenal
A nurse recognizes that diseases of adaptation are most likely to occur when:
A) Individuals have not had to face stress in the past. B) Individuals inherit maladaptive genes. C) Existing conditions exacerbate stress. D) Physiological and psychological resources become depleted.
The spouse of a patient who is scheduled for ECT (electroconvulsive therapy) asks, "Isn't this a risky treatment? I know pills haven't worked, but this seems barbaric to me."
Which response to the question is of greatest therapeutic communication value? a. "Although no treatment is perfect, research has proven that this therapy has the same risk as minor surgery and actually presents a lower risk than medication.". b. "The psychiatrist would not order a treatment that would place your spouse in any real danger. I've seen many patients respond well to this treatment.". c. "That's an understandable concern. However, you've been misled by outdated information that stigmatizes ECT treatment.". d. "You appear to be very concerned about consenting to the treatment. I'd suggest you discuss this with your spouse's health care provider.".