The nurse knows which of the following clinical manifestations indicate severe dehydration?
• Obtunded level of consciousness, faint pulse, extreme thirst, and cool limbs indicate severe dehydration.
• Decreased urine output and capillary refill time of greater than 2 seconds are both indicative of mild dehydration.
• Dry mucous membranes and slow skin turgor indicate moderate dehydration.
• Bradycardia and back pain are not indicators of severe dehydration.
A patient is seen in the clinic for a large mass on the anterior portion of the neck. The patient complains of constipation and depression. The nurse understands these signs and symptoms to be consistent with
A family member of a client with severe dehydration asks the nurse, "What are the common causes of dehydration?" The nurse appropriately answers by explaining
A diabetic patient is admitted to the hospital with a blood glucose of 395 mg/dl. The nurse assesses the patient for which clinical manifestations of hyperglycemia?
A patient who is one-day post knee replacement surgery has a nursing diagnosis of acute pain. Which is the most appropriate short-term goal for this patient?
A patient is seen in the clinic for ulcerative colitis, a form of inflammatory bowel disease. The nurse should anticipate including which of the following in the patient's care plan?
A nurse is caring for a hospitalized client who was admitted for GI bleeding with a history of gallstones. Which of the following findings would the nurse report to the physician immediately?
A patient is admitted to the hospital with a diagnosis of acute hepatitis B. The nurse would expect a rise in which of the following serum labs?
A patient with Crohn's disease is admitted to the hospital for a possible complication. The nurse knows that complications of Crohn's disease include which of the following?
A nurse is caring for a patient who is scheduled to have a barium enema the following day to check for the presence of colon polyps. When the nurse enters the patient's room during rounds, which of the following should alert the nurse?
A patient has developed the cardiac arrhythmia Torsades de Pointes. The nurse should prepare to administer
The nurse is instructing a patient with Cushing's disease. Which of the following statements by the patient indicates an understanding of the management of Cushing's disease?
A nurse is performing an abdominal assessment on a healthy 45-year-old. The nurse should perform the assessment in which order?
A nurse is educating a patient with emphysema who requires oxygen use at home via nasal cannula. The nurse should instruct the patient not to exceed which flow rate?
A patient is admitted to the hospital after his urinalysis showed significant proteinuria. The nurse determines that the patient is suffering from nephritic syndrome, rather than nephrotic syndrome, because of:
The nurse caring for a patient with severe hypothyroidism is providing comfort interventions. Which of the following is appropriate?
While providing discharge instructions to a patient with systemic lupus erythematosus (SLE), the nurse should include which of the following statements?
The nurse is instructing a patient with gastroesophageal reflux disease (GERD) on potential complications if the disease is left untreated. The nurse includes which of the following?
A patient with Raynaud's disease is admitted to the hospital. The nurse assesses the patient for which expected clinical manifestations?
An elderly patient with a five-day history of diarrhea and vomiting is brought to the emergency room (ER). The patient is diagnosed with hypovolemic shock. The nurse recognizes which signs as advanced shock?
A nurse at a dermatology clinic is instructing the patient on risk factors for skin disorders. Which of the following should be included?
A patient obtained multiple burns, with airway involvement, after a motor vehicle accident. Which nursing diagnosis is most important?
A nurse is caring for a client with a dislocated right shoulder. What are the appropriate techniques for neurovascular assessment?
The nurse is assessing a patient admitted with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding suggests this condition?
The nurse is caring for a patient who underwent an angioplasty of the iliac artery. In order to assess for bleeding, the nurse should
A patient recently diagnosed with primary hypertension asks the nurse about the risk factors. The nurse lists the risk factors for primary hypertension, including which of the following?
A patient is admitted to the orthopedic unit after the application of a cast. While transferring the patient into bed, the nurse should:
The nurse is caring for a patient with a closed ulna fracture after the application of a cast. After the patient complains of severe pain, the nurse administers an analgesic and applies an ice pack. When the patient states that the medication provided no relief, the nurse should be alert to the possibility of: