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Allergic Reaction
Indicated by joint pain as a response to medication
Auditory Hallucinations
Schizophrenic client hearing voices telling them to harm others
Electroconvulsive Therapy
Treatment for depression with increased risk due to hyperthyroidism
Rheumatoid Arthritis
Nurse should report ESR of 75 mm/hr in a client's lab results
Mechanical Ventilation
Effective suctioning indicated by decreased peak inspiratory pressure
Seclusion Room
Client with violent behavior should be managed assertively by the nurse
Adrenalectomy
Priority postoperative action is monitoring fluid and electrolyte status
Surgical Procedure
Nurse should respect client's decision to refuse surgery
Borderline Personality Disorder
Improved condition indicated by decreased clinging behavior
Healthy Snack Options
Nurse should recommend air-popped popcorn for school-age children
Enoxaparin
Nurse should teach client to take acetaminophen for pain relief concurrently
Fibromyalgia
Nurse should administer pregabalin for pain in a client with fibromyalgia
Digoxin Toxicity
Risk indicated by potassium level of 3.1 mEq/L in a client with CHF
Alteplase
, Contraindicated in a client with a history of hip arthroplasty 1 week ago
Implantable Cardioverter Defibrillator
Client understands teaching if they avoid microwave oven use
Indwelling Urinary Catheter
Dark yellow urine drainage at 25ml/hr requires obtaining a urine specimen
Stillbirth
Nurse should offer to take pictures of the newborn for the grieving client
Burn Injury
Priority action to prevent wound infection is using sterile dressings
Alzheimer's Disease
Nurse should assist caregiver in arranging a daycare program for the client
Postpartum Urinary Retention
Nurse should perform a fundal massage for a client unable to urinate
Medication Reconciliation
Nurse should compare home medications to admission prescriptions
Betamethasone
Adverse effect is hypotension in a client with preterm labor at 25 weeks gestation
Central Venous Catheter Blood Sample
Actions include aspirating for blood return and flushing with sodium chloride
Preschooler Dressing Change
Prepare child by explaining the procedure in simple terms
Deep-breathing methods
Techniques taught to a child before a medical procedure.
Abdominal incision wound care
Process including irrigating with a 10-mL syringe and using low-pressure flow.
Client prioritization
Determining which client to see first based on conditions like gestation week and symptoms.
Amputation recovery report
Information to share with an occupational therapist, e.g., living situation and allergies.