After an older adult falls, the nurse suspects the development of a subdural hematoma based on which assessment findings? (Select all that apply.)
a. Increasing irritability
b. Complaint of a dull headache
c. Frequent "nodding off" in chair during the day
d. Focal seizures
e. Staggering gait
A, B, C
Increasing irritability and complaint of headache as well as changing level of consciousness are signs of increasing intracranial pressure. Seizures and staggering gait are not specifically indica-tive of subdural hematoma.
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While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action?
a. Add an additional 0.5 mL of air to the balloon and repeat the procedure. b. Advance the catheter with the balloon deflated and repeat the procedure. c. Deflate the balloon and obtain a chest x-ray study to determine line placement. d. Lock the balloon in the inflated position and flush the distal port of the PAC with normal saline.
A client has been diagnosed with a dissociative disorder. What treatments would the nurse know could be used for this client? (Mark all that apply.)
A) Electroconvulsive therapy B) Seclusion therapy C) Hypnosis D) Creative art processes E) Cognitive techniques
A postpartum patient is prescribed methylergonovine (Methergine) 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the patient?
A) Assess ambulation. B) Measure urine output. C) Measure blood pressure. D) Evaluate current hematocrit level.
The nurse is preparing to administer oral medication to an 11-month-old infant who drinks formula from a cup. The nurse decides to use which of the following for medication administration to this child?
a. a dropper c. medicine cup b. a nipple d. infant restraint