The nurse asks the 84-year-old client to look at the finger positioned overhead without the client moving her own head. The client's eyes move upward and focus on the finger for 2 seconds, and then drift down to the standard position
The nurse's best action is which of the following? A. Repeat the test while holding the client's head in a fixed position.
B. Perform cover/uncover eye test.
C. Document the finding.
D. Notify the physician.
C
In the older adult, decreased muscle tone impairs the ability to maintain an upward gaze and to sustain convergence. Therefore, this finding is normal for an older adult client.
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The relief charge nurse has assigned a newly licensed baccalaureate-prepared nurse to be one of the team leaders for the 3-11 shift. In making this decision, the charge nurse has overlooked this nurse's:
a. Clinical expertise. b. Leadership ability. c. Communication style. d. Conflict-resolution skills.
A client who recently developed paralysis of the arms is diagnosed with conversion disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the care plan?
A. Exercising the client's arms regularly B. Insisting that the client eat without assistance C. Working with the client rather than the family D. Teaching the client how to use nonpharmacologic pain-control methods
The nurse is caring for a pediatric patient recently diagnosed with severe combined immunodefi-ciency (SCID) disease. The nurse determines that teaching has been effective after the parent makes which statement?
a. "This disease is like a pediatric version of AIDS." b. "My child must be careful not to fall to avoid bleeding." c. "My child should not attend day care." d. "This problem happened because of che-motherapy treatments."
The nurse discusses changes in a client's health status with the physician. This is an example of which type of communication?
a. Social communication b. Interdisciplinary communication c. Therapeutic communication d. Metacommunication