If the patient appears to be using the muscles of the neck or abdomen for breathing, inform the nurse
Indicate whether the statement is true or false
True
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The child is receiving chemotherapy for acute lymphocytic leukemia. The nurse recognizes that a potential oncological emergency for this child would be tumor lysis syndrome. For which symptoms should the nurse monitor this child?
1. Respiratory distress and cyanosis 2. Thrombocytopenia and leukocytosis 3. Oliguria and altered levels of consciousness 4. Upper-extremity edema and neck vein distension
The nurse assesses a patient's bowel patterns and stools after he has returned from a barium enema study. Which of the following findings based upon the assessment of the stool will the nurse report to the physician?
A) Large, wide stools B) Milky white stools C) Three stools during an 8-hour period of time D) Stools with streaks of blood throughout the fecal material
A primigravida patient arrives in the labor and delivery unit and describes her contractions as occurring every 10–12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor
On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor? 1. Second phase 2. Latent phase 3. Active phase 4. Transition phase
A wound care nurse is assessing a 76-year-old client. The client has intimated to the nurse that her son sometimes "flies off the handle and gets rough with me." Which response made by the nurse is the best response?
A) "When you say 'gets rough,' what does that look like?" B) "What do you think usually provokes this to happens?" C) "I'm going to have to phone adult protective services right now." D) "Why do you think that there is that response with anger or frustration?"