While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night
The nurse disregards this complaint, thinking that no correlation has been noted between having a leg cast and developing restless sleep. A more theoretically sound approach would be to first a. Document the sleep patterns and complaint in the patient's chart.
b. Tell the patient you are just focused on the leg right now.
c. Explain that a more thorough assessment will be needed next shift.
d. Ask the patient about his usual sleep patterns and the onset of having difficulty resting.
D
The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient's complaints.
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A nurse is caring for a client receiving the anticoagulant drug warfarin. Which assessment would be most appropriate before administering the drug?
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a. Pad the edges of the cast. b. Notify the physician immediately. c. Administer an analgesic as ordered. d. Perform neurovascular check on fingers.