To prevent autonomic dysreflexia, which nursing action would the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

A 55-year-old male was admitted 1 week ago for a left lower leg venous thromboembolism, confirmed by ultrasound. He started to work from home 4 months ago and reports that his activity level has significantly decreased. When admitted, his left lower leg had 3+ edema and was warm and reddened over the calf area. He was immediately started on intravenous heparin therapy, with warfarin (Coumadin) on the same day. The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate?

Marvin is transferred from the ICU to the Tele/Neuro unit 24 hours after receiving tPA. He has left sided hemiplegia with some dysphagia. What nursing interventions should be part of his plan of care? Select all that apply.

Based on the patient's current condition, the nurse recognizes that the patient's priority needs will be to prevent:

Mr. Carter, a 35-year-old male, presents to the clinic with complaints of fatigue, nausea, intermittent abdominal pain, and jaundice. He reports that he recently returned from a week-long trip to a rural area in Southeast Asia, where he ate local food and drank untreated water. He denies any history of alcohol use or intravenous drug use.

Laboratory results include:

ALT (Alanine Aminotransferase): 1,200 U/L (Normal range: 7–56 U/L).

AST (Aspartate Aminotransferase): 1,000 U/L (Normal range: 10–40 U/L).

Total Bilirubin: 5.5 mg/dL (Normal range: 0.1–1.2 mg/dL).

Hepatitis A IgM: Positive (Normal range: Negative).

Social History:
Works as a teacher.
Lives alone.

Identify the priority nursing interventions for Mr. Carter (select all that apply):

Mr. Carter, a 35-year-old male, presents to the clinic with complaints of fatigue, nausea, intermittent abdominal pain, and jaundice. He reports that he recently returned from a week-long trip to a rural area in Southeast Asia, where he ate local food and drank untreated water. He denies any history of alcohol use or intravenous drug use. Laboratory results include:

Medications: None reported.

Social History: Works as a teacher, lives alone.

Identify the priority nursing interventions for Mr. Carter. (Select all that apply)

KB is a 65-year-old man admitted to the hospital after a 5-day episode of "the flu" with symptoms of dyspnea on exertion, palpitations, chest pain, insomnia, and fatigue. KB was diagnosed with Graves' disease 6 months ago and placed on methimazole (Tapazole) 15 mg/day. His other past medical history includes heart failure and hypertension requiring antihypertensive medications; however, he says that he has not been taking these medications on a regular basis. Vital signs (VS) are 150/90, 124 irregular, 20, 100.2°F (37.9°C). Admission assessment findings are height 5 ft 8 in (173 cm), weight 132 lb (60 kg), appears anxious and restless, loud heart sounds, bounding radial pulses, 1+ pitting edema noted in bilateral lower extremities, diminished breath sounds with fine crackles in the posterior bases, and hyperactive bowel sounds. KB begins to cry when he tells you he recently lost his wife. You notice someone has punched several more holes in his belt so he could tighten it.

Which of KB's assessment findings represent manifestations of hypermetabolism related to the effect of excess circulating thyroid hormone? Select all that apply.

Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

Which assessment findings are consistent with cirrhosis? Select all that apply.

A 38-year-old female client was diagnosed with a right lower extremity deep vein thrombosis (DVT) after surgery 2 days ago. This morning the nurse reviews the client's electronic health record to complete a shift assessment. Data from the health record include a prescription from the primary health care provider for warfarin 5 mg orally every day, and the following laboratory results:

• Hemoglobin: 17 g/dL
• Hematocrit: 44.9%
• WBC count: 5500/mm³
• Platelets: 160,000/mm³
• aPTT: 40 sec
• PT: 12 sec
• INR: 0.9
• BUN: 16 mg/dL
• Creatinine: 0.6 mg/dL

The nurse assesses the client for which signs and symptoms of a DVT?

Important nursing interventions when caring for a patient with Cushing syndrome include: