A nurse assesses a patient's risk for developing a pressure ulcer using the Norton scale. The patient's score is 18 . What nursing action should be implemented?
a. Call the physician immediately.
b. Implement a pressure ulcer prevention program.
c. Document the score.
d. Order an alternating air mattress.
C
If the total score on the Norton scale is greater than 14, then little risk exists for the development of pressure ulcers. If the total score is less than 14, then significant risk exists.
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Your new patient admitted to the psychiatric unit is pacing and agitated. Which of the following is the most appropriate intervention?
A. Introduce the patient to all the other patients. B. Direct him to a group therapy session. C. Place him in a quiet area away from other patients. D. Review the unit rules with the patient to distract him.
A nurse should notify the physician immediately if a client taking a cholinergic drug develops which of the following?
A) Hypoglycemia B) Excessive salivation C) Severe abdominal cramping D) Muscle rigidity E) Muscle spasms
An older adult patient reports burning and itching eyes. On assessment, the nurse notes swelling of the eyelid margins bilaterally. What additional data are necessary to confirm the nurse's sus-picion of blepharitis?
a. The patient reports visual disturbances such as rainbow halos. b. The eyelids are reddened from seborrhea. c. The patient is being treated with anticoa-gulants. d. Small corneal hemorrhages are present.
Estrogen and progesterone are two female sex hormones that allow pregnancy to occur and help maintain a pregnancy
Indicate whether the statement is true or false.