The nurse is caring for a patient who is taking digitalis. The patient complains of increased thirst, and the nurse observes dry mucous membranes. Which additional finding warrants the nurse's immediate attention?
a. Sudden, sharp knee pain
b. Blurred vision
c. Epistaxis
d. Chills
B
Blurred vision, halos around lights, nausea, vomiting and diarrhea, and fatigue are all indicators of toxicity to digitalis. Assessment is especially important for the dehydrated patient because of the rising potassium level.
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The nurse is caring for a patient who has a fractured pelvis with a left acetabular fracture and is in a Thomas splint with a Pearson attachment with orders of bedrest. When the patient asks to toilet, which of these measures would be appropriate?
a. Ask patient to lift straight up using a trapeze mounted above the bed and slide a bedpan underneath from the right side. b. Turn patient onto right side, place the bedpan behind, and turn back. c. Help patient up on a commode very carefully. d. Have patient sit up as high as possible and lift self up with hands pushing on the bed, then slide the bedpan underneath.
A patient who sustained a T3 spinal cord injury one month ago is now entering the rehabilitation phase of his treatment. The nurse developing goals and measurable outcomes for his treatment is working in which step of the nursing process?
A) Assessment B) Planning C) Diagnosis D) Evaluation
Which of the following is a characteristic of the helping relationship?
A) it occurs spontaneously B) it is similar to a social relationship C) it is an unequal sharing of communication D) it is based on the needs of the nurse
One of the most common terrorist activities is the use of explosives. A common trauma associated with this is Blast Lung Injury. What are the symptoms that would alert a nurse to this problem? The patient presents with
1. Air emboli and pneumothorax 2. The inability to think rationally 3. Dyspnea, hemoptysis, cough, and chest pain 4. Black sputum.