Chatty Cathy

A patient is suffering from a internal hemorrhage. What are signs and symptoms of internal hemorrhage? (select all that apply) A. distention or swelling of the affected body part. B. elevated WBC C. decrease in blood pressure and increase in pulse D. change in the type and amount of drainage.

(A) distention or swelling of the affected body part. (C) decrease in blood pressure and increase in pulse

After coming back from lunch, you notice Chatty Cathy walking around the unit. She is wearing non-grip socks and a wristband that indicates fall risk. What is the first thing the nurse should do? a. sit the patient in a chair and find a nurse aide to help b. walk the client back to her room and assist her back to bed. c.educate the client that walking around her room is the safest practice d. Encourage the patient to walk to build strength.

(b) walk the client back to her room and assist her back to bed.

The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct the client to avoid the VALSALVA MANEUVER when defecating? (SELECT ALL THAT APPLY) 1. 22 year old man with a head injury sustained during a college football game. 2. 30 year old woman recently hospitalized for reconstructive augmentation mammoplasty. 3. 56 year old man 2 weeks post myocardial infarction. 4. 68 year old woman recently diagnosed with pancreatic cancer. 5. 74 year old man with portal hypertension related to alcohol induced cirrhosis 6. 82 year old woman 1 week post cataract surgery.

1. 22 year old man with a head injury sustained during a college football game. 3. 56 year old man 2 weeks post myocardial infarction. 5. 74 year old man with portal hypertension related to alcohol induced cirrhosis 6. 82 year old woman 1 week post cataract surgery.

A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse? A) complete a fall-risk assessment B) educate the client and family about fall risks C) eliminate safety hazards from the client's environment D) make sure the client uses assistive aids in his possession

A:) complete fall-risk assessment

What are nursing interventions and assessment of an older adult clients neruological system? SATA A. Perform a complete mental status examination, including depression B.Monitor BP and hydration status C.Screen for cognitive impairment D. Minimize potential sources of injury in the environment E.Teach individual relaxation techniques, stress management, and adaptive self-care management

ALL ARE CORRECT!

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

Which nursing intervention is most effective in reducing a patient's risk of falls? A. Leave the call light in reach B. Ensure the patient's room is close to a bathroom C. Frequent rounding D. All four side rails are upright

C

A nurse is monitoring an elderly patient with a head injury for increased ICP. Which of the following clinical manifestations should the nurse report to the healthcare provider immediately? (SATA) A. Bradycardia B. Change in LOC C. Systolic hypertension D. Irregular respirations E. Diaphoresis

A, B, C, D

A health care professional should monitor an older adult patient who is taking Ativan for which of the following adverse effects? (SATA) A. Orthostatic Hypotension B. Blurred Vision C. Drowsiness D. Consitpation E. Respiratory Depression

A, B, C, E

The nurse is instituting seizure precautions for a client who is is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. A. Padding the side rails of the bed. B. Placing an airway at the bedside. C. Putting a padded tongue blade at the head of the bed. D.Placing oxygen and suction equipment at the bedside. E. Flushing the intravenous catheter to ensure that the site is patent.

A,B,D,E

What advice would you offer to a client to prevent falls at home? Select all that apply. A.) Clean up clutter B.) Install grab bars and handrails C.) Allow their small dog to run around freely D.) Install nonslip mats on slick surfaces. E.) Keep lights dim throughout the home

A. B. D

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? A.) Tomato soup B.) Boiled shrimp C.) Instant oatmeal D.) Summer Squash

D.

A nurse is caring for an older adult with impaired mobility. Which of the following should the nurse consider when planning the client's daily activities? A. The skin of older adults is thicker and may slough more easily B. Hyperreflecia in the older adult affects transer techniques and modifications may be necessary C. Provide analgesia and skin care for the older adult every day after activities D. Older adults who have been sedentary for long periods may be more likely to develop orthostatic hypotension

D. Older adults who have been sedentary for long periods may be more likely to develop orthostatic hypotension