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1 . What assessment findings should he nurse document in the electronic medical record for a client who is experiencing autonomic dysreflexia after a T-4 spinal cord injury - answer-- Severe hypertension, diaphroresis, and flushing above the lesion 2 . As the nurse is turning a client with a chest tube, the chest tube becomes dislodged from the pleural space. What action should the nurse take first? - answer-- Have the client exhale forcefully and tape 3 sides of a sterile gauze over the in...

Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement? - answer-Remove cigarettes for the client's room A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply...

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records what is said. C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort. - answer-A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that note-taking during the interview has disadvantages....

The nurse assumes care of a postoperative adult client with diabetes mellitus and learns that the client has a current blood glucose level of 720 mg. When assessing the client what is the priority? A. Assess for vital signs of fluid volume deficit. B. Observe wound drainage characteristics. C. Measure the level of acute pain. D. Determine when the client last ate. - answer-A. Assess for vital signs of fluid volume deficit. A male client tells the nurse that he is concerned that he may hav...

A multiparous client has been in labor for 8 hours when her membranes rupture. Which action should the nurse implement first? Prepare the client for imminent birth. Assess the fetal heart rate and pattern. Document the characteristics of the fluid. Notify the client's primary healthcare provider. - answer-Assess the fetal heart rate and pattern. A primigravida at 37 weeks gestation tells the nurse that her "bag of water" has broken. While inspecting the client's perineum, the nurse no...

Which color-tagged clients usually make up the greatest number in most large-scale multi-casualty situations, based on the disaster triage tag system? Red Black Green Yellow Green Rationale Green-tags clients usually make up the greatest number in most large-scale multicasualty situations. These clients have minor injuries and they may actually evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Red-tagged clients have major injuries, black-tag...

A client presents to the emergency department (ED) with complaints abdominal pain. The nurse observes the client's right cheek and eye bruised and suspects possible domestic violence. Which approach is best the nurse to use when interviewing the client? a. Share personal values to put the at ease b. Ask questions in a vague, non-specific format c. Begin with questions that are less sensitive in nature d. Get the most difficult questions over with fist - answer-c. Begin with questions ...