A home care client who is currently on hydromorphone (Dilaudid) for pain management presents to the hospital reporting abdominal cramping, nausea, and sweating. When taking the client's history, the nurse asks which question first?
a. "Are you currently in severe pain?"
b. "Did you take more Dilaudid than pre-scribed?"
c. "When did you take your last dose of Di-laudid?"
d. "When was your last bowel movement?"
C
Physical dependence occurs in everyone who takes opioids over a period of time. Withdrawal syndrome occurs when the client abruptly stops taking the medication. Symptoms include abdo-minal cramping, nausea, sweating, delirium, and convulsions. Although the other distractors may be asked about as part of the admission assessment, they are not of priority.
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A patient is brought to the emergency department having had a rock chip embedded in the right eye. What should be the nurse's initial action?
a. Turn the patient to the left side and pre-pare to remove the chip. b. Flush the right eye with normal saline. c. Keep the patient flat. d. Cover both eyes.
In your nursing practice you believe in doing good and that prevention of harm, removal of evil, and promotion of good are extremely important. Your practice adheres to which ethical principle?
a. Beneficence c. Fidelity b. Justice d. Veracity
To determine if a client has an initial manifestation typically seen in clients with bladder neoplasm, the nurse would ask
a. "Do you have pain when you urinate?" b. "Do you produce larger amounts of urine than you have in the past?" c. "Have you noticed any blood in your urine?" d. "Have you noticed that you urinate more frequently than you used to?"
Which statement made by a client would alert the nurse to the presence of edema?
A. "I seldom sleep soundly at night." B. "My shoes seem to be fitting tighter." C. "I seem to feel more anxious lately." D. "I drink at least two full glasses of water a day."