The care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex. The nurse knows that she should as-sess for:
1. extremely elevated blood pressure after ambulation.
2. nausea and vomiting after a meal.
3. lightheadedness and fainting during defecation.
4. inability to urinate.
1
Constipated individuals may strain to defecate, causing an increase in intraabdominal pres-sure. This is called the Valsalva maneuver or vasovagal reflex, and it can lead to cardiovas-cular alterations.
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A client with acute mania is a business executive. He tells the nurse that his job is only his cover,
that he's really the right-hand man to the president of the United States and that he has been sent to this city to reorganize the FBI and CIA. A desired outcome for this client is that he will a. use his executive skills to organize unit activities. b. consistently display distorted thought self-control. c. demonstrate acceptance of unit policies. d. act out feelings.
A patient arrives in the emergency department complaining of muscle weakness and drowsiness. The nurse notes a heart rate of 80 beats per minute, a respiratory rate of 18 breaths per minute, and a blood pressure of 90/50 mm Hg
The electrocardiogram reveals an abnormal rhythm. The nurse will question the patient about which over-the-counter medication? a. Antacids b. Aspirin c. Laxatives d. Potassium supplements
The nurse is assessing a patient who is intubated and on a ventilator. When listening above the sternal notch with a stethoscope, the nurse notes a minimal amount of air leak at the end of inspiration. Which action by the nurse is appropriate?
a. Remove all air from the cuff and reinflate the cuff until no air leak is present. b. Note that the cuff is properly inflated. c. Notify the health care provider. d. Suction the patient.
Calculate the amount to administer and choose the correctly marked syringe: syringe ________. Ordered: Lanoxin 0.125 mg deep IM massage stat On hand: Lanoxin 0.25 mg/mL 
Fill in the blank(s) with the appropriate word(s).