Answer to Question 1
B
Feedback:
The nurse should monitor the level of consciousness of the client. The nurse should avoid touching the client, because the client may react violently to physical contact. The nurse should monitor for a decrease in respiratory rate instead of an increase in respiration. The nurse should turn off the television and provide a calm environment to the client instead of encouraging the client to watch television.
Answer to Question 2
C
Feedback:
With urticaria (hives), reddened areas (erythema), itching (pruritus), and burning around swollen patches on the skin may appear. They appear suddenly and may disappear after a few hours or may last for a period of days or weeks. Hives can result from a variety of causes, including foods; additives; medications; viral, bacterial, or parasitic infections; or stress factors (e.g., heat, sun, cold, emotional stress). Asthma is an example of a respiratory response, and latex sensitivity is an example of an allergy with a multisystem response. A food allergy may cause a gastrointestinal response.
The nurse assesses the patient's ability to use the walker correctly
The postoperative client supports an incision with a folded pillow when taking a deep breath and cou
A nurse communicates with her non–English-speaking patient through an interpreter
An emergency department physician at work
Measuring the client’s height with a platform scale
Positioning the client