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Glasgow Coma Scale of 3
ANSWER:
Expect nonresponsive to commands
Angina Manifestations
ANSWER:
Chest discomfort radiated, pain <15mins, relieved with rest
Diabetes Mellitus Client
ANSWER:
Plan to see diaphoretic client first
Testicular Self-Examination
ANSWER:
Instruct to examine after a warm shower
Tuberculosis Combination Therapy
ANSWER:
,Adherence indicated by negative sputum culture
Bacterial Meningitis
ANSWER:
Expect severe headache
Pernicious Anemia Teaching
ANSWER:
Client understanding: switch to nasal cyanocobalamin
Right-Sided Hemiparesis ADLs
ANSWER:
Include combing hair with unaffected arm
COPD Discharge Teaching
ANSWER:
Include pursed lip breathing technique
Varicose Veins Instruction
ANSWER:
Teach to apply elastic support hose in the morning
Total Knee Arthroplasty Transfer
ANSWER:
Flex at hip and knees before transferring
Thoracentesis Teaching
ANSWER:
Lean forward on over bed table for procedure
Alzheimer's Sleep Promotion
ANSWER:
,Provide light snack of cheese and crackers at bedtime
Nicotine Chewing Gum Use
ANSWER:
Recommend no eating/drinking 15min around gum use
Diabetes Foot Care
ANSWER:
Prop feet up while watching TV
Neurogenic Bladder Interventions
ANSWER:
Include stroking inner thigh in plan for bladder control
Systemic Lupus Erythematosus
ANSWER:
Expect joint pain in the client
GERD Dietary Teaching
ANSWER:
Instruct to avoid peppermint
Enteral Feedings with Medications
ANSWER:
Flush tube with water before and after each medication
Oxygen Concentrator Safety
ANSWER:
Include maintaining electrical backup system
Hypoglycemia Management
ANSWER:
, Have client drink a glass of milk for glucose <50mg/dL
Hypertension Dietary Selections
ANSWER:
Instruct to avoid pretzels for sodium intake
Pheochromocytoma Findings
ANSWER:
Expect hypertension in the client
Gastric Lavage Teaching
ANSWER:
Inform about semi-upright position during the procedure
Right-Sided Heart Failure Findings
ANSWER:
Expect peripheral edema, hepatomegaly, abdominal distension
Neutropenia Care
ANSWER:
Include bathing with antimicrobial soap, daily temperature checks,
and avoiding gardening
Alzheimer's Home Care
ANSWER:
Include labeling kitchen cabinets and drawers for caregiver
Low Sodium Level
ANSWER:
Nurse is collecting data from a client with sodium level of 128mEq/L
Mental Confusion