A pregnant woman with severe preeclampsia is receiving intravenous magnesium sulfate at 3 g/hr. Her serum magnesium level is 7 mg/dL. What is the most important nursing assessment?
A) Decreased incidence and frequency of seizures
B) Decreased respiratory rate and hyporeflexia
C) Increased urine output greater than 40 mL/hr
D) Flushing of skin and diaphoresis
B
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Mary believes that her husband John is having an affair because he has become increasingly distant, disinterested in romance, and works late. John is in charge of an important project at work that is running behind and causing stress
Mary asks her daughter if she has noticed anything different about her father, and when the daughter mentions it to her father, the father tells her to tell her mother that he cannot deal with her insecurities right now. Which nursing diagnosis should the nurse therapist make her initial priority? a. Defensive coping b. Impaired parenting c. Interrupted family processes d. Dysfunctional family processes
The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. The nurse documents this finding as:
A) Confusion B) Obtunded C) Stupor D) Coma
Which nursing diagnoses would the nurse use for a client prone to falls?
1. Deficient Knowledge 2. Risk for Injury 3. Risk for Disuse Syndrome 4. Risk for Suffocation
MC The RN observes two team members placing the bed clothes they have taken off a client's bed on the floor. The appropriate intervention is to
A. Bring the staff members a clothes basket and tell them to use it the next time. B. Explain the principles of medical asepsis to both team members. C. Tell them that this is unacceptable behavior and you will counsel both of them later. D. Do nothing because the bedclothes are on their way to the laundry to be disinfected.