A client persents with symptoms of increased intracranial pressure, papilledema, and headache. No history of trauma is found. Vital signs are BP 110/60, HR 80, T 98.9 degree F, RR 24. Based on this statement, the nurse suspects the client has a(n):
A. brain tumor
B. meningitis
C. skull fracture
D. encephalitis (more…)
Mr. Jim a 65 year old retired steel worker is admitted to the unit with dyspnea upon exertion. He has a long history of smoking. Initial assessment findings include barrel chest, ankle edema, persistent cough with copious sputum production, and variable wheezing on expiration. Laboratory test result include a hematocrit greater than 60% and a partial pressure of carbon dioxide in arterial blood (PaCO2) OF 65 mm Hg. The physican diagnostic chronic obstructive pulmonary disease (COPD)
1. Mr.Jim’s ankle edema and respiratory problems should make the nurse suspect hypertrophy of which heart chamber?
A. Left atrium
B. Right atrium
C. Left ventricle
D. Right ventricle (more…)
When the nurse tested an unconscious client for noxious stimuli, the client responded with decorticate rigidity or posturing. This is best described as:
A. flexion of the upper and lower extremities into a fetal-like position
B. rigid extension of the upper and lower extremities and plantar flexion
C. complete flaccidity of both upper and lower extremities and hyperextension of the neck
D. flexion of the upper extremities, extension of the lower extremities, and plantar flexion