When weighing a patient who can stand unassisted, the nurse must make sure to
1. Let the patient get out of bed and walk to the scale unassisted, to respect the patient's boundaries and help maintain the patient's sense of control.
2. Weigh the patient at different times of day to get an average weight over time.
3. Place a hand a few inches behind the patient's back when he steps on the scale, in case the patient loses his balance.
4. Allow the patient to hold on to something while being weighed, if he wishes.
ANS: 3
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When testing your patient for two-point discrimination, you should
a. first touch one fingertip with a sharp object and then a second fingertip, and assess if she can accurately report the sequence. b. simultaneously touch two points of one of her fingers with sharp objects, and assess if she can distinguish the two points. c. simultaneously touch a finger on her right hand and the corresponding finger on her left hand with two sharp objects, and assess if she can distinguish the two points. d. simultaneously touch a fingertip with two sharp objects, remove one stimulus, and then assess if she can detect that one point has been removed.
The clinic nurse is assessing an infant. What are early signs of cognitive impairment the nurse should discuss with the health care provider? (Select all that apply.)
a. Head lag at 11 months of age b. No pincer grasp at 4 months of age c. Colicky incidents at 3 months of age d. Unable to speak two to three words at 24 months of age e. Unresponsiveness to the environment at 12 months of age
Martina is prescribed isocarboxazid to treat mental depression. Which of the following foods can be included in Martina's diet?
A. Fresh meat B. Old cheese C. Beer D. Wine
The nurse is contributing to a patient's plan of care for a patient who has an elevated international normalized ratio (INR). Which of these nursing diagnoses should the nurse recommend receive priority in the patient's care plan?
a. Acute Pain b. Ineffective Breathing Pattern c. Risk for Injury d. Risk for Infection