The nurse is conducting an assessment for a patient on a medical-surgical unit. Which finding is indicative of pain?
1) Constricted pupils
2) Decreased heart rate
3) Decreased blood pressure
4) Abnormal posture
ANS: 4
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A mother brings her severely disabled child to the pediatric clinic with complaints that the child has his fourth upper respiratory infection in 3 months. The mother appears disheveled and fatigued. What action by the nurse is best?
A. Ask the mother when the last time she ate or bathed was. B. Inquire as to the whereabouts of the child's father. C. Make a referral to the visiting nurses for a home evaluation. D. Offer the mother information on local respite care options.
To assess the patient's visual acuity, the nurse should use the
a. ophthalmoscope c. Snellen chart b. otoscope d. pen light
A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication?
a. 5% human albumin b. Furosemide (Lasix) IV c. Epinephrine (Adrenalin) drip d. Hydrocortisone (Solu-Cortef)
A child is diagnosed with hyperthyroidism. What finding would the nurse expect to assess?
What will be an ideal response?