David Montanari is a 19-year-old male who suffered a T4-T5 burst fracture as a result of a motorcycle accident on Sunday. He underwent spinal fusion on Sunday evening and has had an uneventful recovery period. David has no sensation or movement below the nipple line and is bed bound. Yesterday evening, his indwelling urinary catheter was discontinued in an attempt to begin bladder retraining. The last bladder scan and straight catheterization were done at midnight. The scenario takes place on Thursday at 0800 during the morning nursing assessment.  David Montanari is lying supine in bed with the head of bed at 15 degrees. David’s mother, Janene Montanari, is at the bedside and is anxious about her son’s condition. Assessment Data T = 98.2 F (36.8 C)BP = 150/88P = 48RR = 24O2 Sat = 96% (room air)• Heart sounds: Regular• Lung sounds: Clear• Bowel sounds: Present• Pulses: 3+• Pain: Surgical site pain is 2/10; headacheis 10/10 You suspect autonomic dysreflexia. What assessment findings would support this problem? Select all that apply.

Brooke Gentry, Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a 12-hour elective oxytocin induction of labor. She had an uncomplicated labor, epidural anesthesia and a rapid second stage, no episiotomy or perineal lacerations. Indwelling urinary catheter was removed prior to delivery. She is now one hour postpartum and is breastfeeding her baby. An IV of 1000 mL Lactated Ringers is infusing at KVO rate with an infusion of Lactated Ringers with oxytocin 20 Units infusing IVPB at 125 mL/hour. Upon entering her room, she tells you that she “feels wet”, and may have urinated on herself since she is still numb from the epidural and unable to move legs.  She is anxious, appears pale, and complains of feeling light-headed. Her husband is at her bedside. Assessment findings: Blood pooling under buttocks with several large clots; fundus boggy and slightly deviated to the right, 3 cm. above umbilicus; Vital signs: BP 90/60, P 110, R. 20, SAO2 98%, skin color pale, patient alert and oriented; unable to move legs, holding and breastfeeding baby.  In what order would you perform the following interventions: Set oxytocin rate to Bolus on IV pump as ordered by healthcare provider. Call for help using emergency call system. Assist mother to unlatch infant from breast and place infant in crib or hand to husband. Massage uterine fundus. Assess bladder status and need to perform straight catheter.

Brooke Gentry, Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a 12-hour elective oxytocin induction of labor. She had an uncomplicated labor, epidural anesthesia and a rapid second stage, no episiotomy or perineal lacerations. Indwelling urinary catheter was removed prior to delivery. She is now one hour postpartum and is breastfeeding her baby. An IV of 1000 mL Lactated Ringers is infusing at KVO rate with an infusion of Lactated Ringers with oxytocin 20 Units infusing IVPB at 125 mL/hour. Upon entering her room, she tells you that she “feels wet”, and may have urinated on herself since she is still numb from the epidural and unable to move legs.  She is anxious, appears pale, and complains of feeling light-headed. Her husband is at her bedside. Assessment findings: Blood pooling under buttocks with several large clots; fundus boggy and slightly deviated to the right, 3 cm. above umbilicus; Vital signs: BP 90/60, P 110, R. 20, SAO2 98%, skin color pale, patient alert and oriented; unable to move legs, holding and breastfeeding baby.  In what order would you perform the following interventions: Set oxytocin rate to Bolus on IV pump as ordered by healthcare provider. Call for help using emergency call system. Assist mother to unlatch infant from breast and place infant in crib or hand to husband. Massage uterine fundus. Assess bladder status and need to perform straight catheter.

Arthur Harris is a 59-year-old African American male with a history of type 2 diabetes. He was directly admitted from his provider’s office with an infected sacral wound, which developed several months ago while on bed rest following an ankle sprain. He reports a history of depression, currently exacerbated by the death of his wife 6 months ago. Since admission, Arthur has received wound care, antibiotic therapy, and IV pain medications. He has also been receiving correction scale insulin coverage with meals, though his appetite has been poor and he has not been eating well.  Arthur Harris’ friend calls out from the room that Arthur is unresponsive. Arthur is lying supine in bed. His IV is pulled out and fluid is running into a puddle on the floor. What is your priority assessment?

Arthur Harris is a 59-year-old African American male with a history of type 2 diabetes. He was directly admitted from his provider’s office with an infected sacral wound, which developed several months ago while on bed rest following an ankle sprain. He reports a history of depression, currently exacerbated by the death of his wife 6 months ago. Since admission, Arthur has received wound care, antibiotic therapy, and IV pain medications. He has also been receiving correction scale insulin coverage with meals, though his appetite has been poor and he has not been eating well.  Arthur Harris’ friend calls out from the room that Arthur is unresponsive. Arthur is lying supine in bed. His IV is pulled out and fluid is running into a puddle on the floor. What is your priority assessment?

The X.500 standard defines a protocol for a client application to access an X.500 directory known as which of the following options?

To assist with controlling orphaned and dormant accounts, what can be used to indicate when an account is no longer active?

What type of learner tends to sit in the middle of the class and learns best through lectures and discussions?

Andy Martin, 81 year old. Dx-Metastatic CA of Colon, Hx of diabetes. Palliative care. NKD Vital Signs: Temp 98.7 BP 114/67 P 115 R 20 SaO2 98% Neuro WNL alert and cooperative. Skin warm and dry. Blood glucose 185, 4 units of insulin sliding scale for coverage. ADA diet, intake 25% Demerol 25 mg SIVP for pain, reports pain 7/10 on pain scale. Patient and family upset regarding diagnosis. Select the appropriate nursing diagnosis for Mr. Martin. (Select all that apply)

Which of these are considered symptoms of a rotator cuff tear?