HESI METERNITY

Which clinical finding would the nurse anticipate if a client who sustained severe burns over 40% of the surface area of the body develops water intoxication? - ANS Disorientation with twitching Rationale: Excess extracellular fluid moves into cells (water intoxication). Intracellular fluid excess in sensitive brain cells causes altered mental status; other signs include twitching, anorexia, nausea, vomiting, sleepiness, and convulsions. Test-taking tip: the present of absolute words ...

Before administering a laxative to a bedfast client, it is most important for the nurse to perform what assessment? a-Observe the skin integrity of the client's rectal and sacral areas b-assess the client strength in moving and turning in the bed c-evaluate the client's ability to recognize the urge to defecate d-determine the frequency and consistency of bowel movements - ANS D rationale the nurse should ensure that the client is not experiencing diarrhea (answer choice D)...