Of the following patients, who is most likely to need a neurologic assessment?
A) A 2-year-old, in for a well-child visit, sitting quietly on mother's lap
B) An 8-year-old with rhinitis, coloring in a book
C) An 18-year-old car accident victim who appears sleepy
D) A 56-year-old patient with complaints of difficulty breathing
C
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A nurse in a burn unit observes that a patient is tensed up and frowning but silent. The nurse asks the patient, "Can you tell me what you are thinking now?" The patient responds, "I can't take this pain any more! I feel like I'm about to die
" What would be the best response for the nurse to give to the patient, considering that the patient is already receiving the maximum amount pain medication that is safe? A) "Try to get rid of those negative thoughts—they only make it worse." B) "Try thinking instead, 'This pain will go away; I can overcome it.'" C) "Your pain medication is already at the highest possible dose." D) "Would you like me to raise the head of your bed?"
The nurse is performing an assessment on a client and notes that the client has thin arms and legs, purple striae on the abdomen, upper body obesity, and a round red face. The nurse would suspect the client has a disturbance with the:
1. Adrenal gland. 2. Thyroid gland. 3. Parathyroid gland. 4. Hypothalamus.
During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions concerning funeral arrangements and even naming the baby. The nurse's role should be to:
1. take over as much as possible to relieve the pressure. 2. encourage grandparents to take over. 3. make sure that the parents themselves approve the final decisions. 4. let them alone to work things out.
The nurse notes edema in the hands and legs of an elderly hospitalized client who appears undernourished. One of the things the nurse considers is that:
1. The client has been drinking large amounts of water to prevent feelings of hunger. 2. Thyroid hormones are out of balance. 3. The kidneys are failing, causing fluid retention. 4. Lack of adequate protein is causing a fluid shift.