Question 1
A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU). Which nursing diagnosis would have the highest priority based on this positive score?
◦ Memory Impaired
◦ Injury, Risk for
◦ Social Interaction, Impaired
◦ Family Processes, Altered
Question 2
Which nursing action would be appropriate when the nurse initiates an infusion of morphine sulfate for a post-operative patient who is experiencing pain?
◦ Anticipate that the patient will begin to experience the effect of the morphine 15 minutes after the start of the infusion.
◦ Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain.
◦ Begin the infusion at the lowest ordered dose, and increase the rate every 30 minutes if the patient continues to have pain.
◦ Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each time.
Physical assessment is one component of the nursing database
The surgical nurse assists the client into the correct position
Homans Sign Maternal Nursing
Choosing nursing interventions
Mechanisms of action of anticoagulants.
Example of cnidocyte action