A nurse is caring for a client diagnosed with an allergy. Which should the nurse monitor
in the client as signs and symptoms of an allergic response?
A) Vasodilation, edema, and itching
B) Vascular spasm or vasoconstriction
C) Spontaneous platelet plug formation
D) Coagulation process for a fibrin clot
A
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You are transferring a patient who is in the progressive stage of shock into ICU from your medical-surgical unit. You are aware that the shock affects many organ systems and that nursing management of the patient will focus on what?
A) Reviewing the cause of shock and trying to limit the progression B) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care C) Giving the prescribed treatment but shifting focus to providing family time as the patient is unlikely to survive D) Giving progressive care to the patient and family using critical pathways for shock therapy
The nurse has noted that a newly admitted resident to an extended care facility stays in her room, does not take active part in activities, and leaves the meal table after having eaten very little. The nurse analyzes this relocation response as:
1. regression. 2. social withdrawal. 3. depersonalization. 4. passive aggressive.
A child is on rifampin (Rimactane) for treatment of tuberculosis. The parents call the clinic and report that the child's urine is orange. The nurse should advise the parents to
1. bring the child to the clinic for aurinalysis. 2. bring the child to the clinic for an radiograph of the kidneys. 3. expect orange-colored urine whilethe child is on rifampin. 4. encourage the child to drinkcranberry juice.
The nurse has reviewed the functions of the peripheral vascular system with a client. Which statement made by the client indicates further teaching is needed?
A. "Produces red blood cells that transport oxygen." B. "Deliver oxygen and nutrients to tissues of the body." C. "Transports carbon dioxide and waste products from the tissues." D. "Lymphatic system removes pathogens from the body fluid."