After a traumatic brain injury, a patient is found to be positioned with arms extended and hands clenched. Which is the term used to describe this assessment finding?
1) Spinal cord lesion
2) Frontal lobe lesion
3) Decorticate (flexor) posturing
4) Decerebrate (extensor) posturing
ANS: 4
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When planning intrapartum care for a client with heart disease, the nurse should include:
a. taking vital signs according to standard protocols. b. continuously monitoring cardiac rhythm with telemetry. c. massaging the uterus to hasten birth of the placenta. d. maintaining the infusion of intravenous fluids to avoid dehydration.
A ventilated client has become hypoxic, with a pulse oximeter reading falling from 98% to 88%. The high-pressure alarm is sounding on the ventilator. The nurse has checked the tubing integrity and found no problems
The nurse has assessed the lung sounds and the sounds are equal bilaterally, but adventitious sounds are present. What action will the nurse take next? 1. Suction the client. 2. Contact the health care provider. 3. Turn the client on his side. 4. Silence the alarm.
A patient asks the nurse why an anticoagulant has been prescribed. What is the nurse's best response?
a. "It will dissolve any clots in your blood vessels." b. "It will prevent any new clots from forming." c. "It will prevent a clot from migrating." d. "It will thin your blood."
Wendy is a nursing student who is admitting Mrs. Williams, a 75-year-old patient into the gastrointestinal laboratory for a routine colonoscopy. During the assessment, Wendy learns that Mrs
Williams lost her husband 4 months ago to stomach cancer and has not been sleeping well. Which of the following is the best question to obtain more data regarding Mrs. Williams' sleeping pattern? A. "Are you taking medication to help you sleep?" B. "How long have you had difficulty sleeping?" C. "What time do you go to bed at night?" D. "Are you taking a nap in the afternoon?"