A physician mentions to a nurse that a newly admitted client is impulsive. The nurse should assess
for behavior characterized by
a. adherence to a strict moral code.
b. manipulative, controlling strategies.
c. postponing gratification to an appropriate time.
d. little time elapsed between thought and action.
D
The impulsive individual acts in haste without taking time to consider the consequences of the
action. None of the other options describes impulsivity.
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A patient with leukemia has been admitted with possible leukostasis. What signs and symptoms does the nurse most expect?
A) Critical neutropenia B) High and persistent fever C) SpO2 82% to 90% D) Diffuse erythematous rash
Admission vital signs for the mechanically ventilated patient in the neurosurgery intensive care unit are heart rate: 60 beats per minute, blood pressure: 110/82, and respiratory rate: 20 breaths per minute. Which statement by the nurse reflects an accurate understanding of the patient's current pain experience?
1. "This patient's vital signs reflect a sympathetic nervous system response to pain." 2. "Since the vital signs are normal, the patient is not experiencing pain." 3. "This patient needs further assessment to determine if pain is present." 4. "Since the patient is mechanically ventilated, pain is unlikely."
In a burn patient with eschar formation around an entire arm, the nurse will include frequent assessment of:
1. urine output. 2. pain level. 3. capillary refill. 4. breath sounds.
A 40-year-old postoperative patient has a hemoglobin level of 8 g/dL and a SaO2 of 95 percent. Considering all aspects, the nurse concludes that the patient
1. has a potential risk of hypoxia. 2. is stable and at no risk. 3. has an elevated SaO2 for their age. 4. is adequately being oxygenated and at no risk for hypoxia.