Which client does the nurse assess first at the start of the nursing shift?
a. Client wanting to know information about a magnetic resonance imaging (MRI) test scheduled in 3 hours
b. Client who is verbalizing mild discomfort after an electromyography (EMG)
c. Client who reports increased pain and swelling after an arthroscopy
d. Client who refuses to drink more fluids after a nuclear medicine scan
C
The client who should be the first priority is the one who is reporting increased pain and swelling after arthroscopy; this could indicate complications from the surgery. The client with mild dis-comfort after an EMG should be assessed for pain, but mild discomfort is common for this pro-cedure. Pain medication can then be administered. After a nuclear medicine scan, the client must increase fluids to flush out the radioisotope used in the scan. The nurse could then visit with the client who had questions about the upcoming MRI.
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The nurse is assisting with a community education program related to cerebral vascular accidents. Which of the following would be included in a list of symptoms that should prompt immediate medical attention? (Select all that apply.)
a. Sudden numbness or weakness of face, arm, or leg, especially on one side of the body b. Sudden confusion, trouble speaking, or understanding c. Sudden trouble seeing in one or both eyes d. Sudden loss of hearing, ringing in the ears, or stabbing ear pain e. Sudden trouble walking, dizziness, or loss of balance or coordination f. Sudden severe headache with no known cause
Tactile agnosia is related to injury of which area of the brain?
a. Frontotemporal b. Parietal c. Temporal d. Broca area
The patient has been exposed to a nerve agent. For which symptoms will the nurse most likely assess?
1. Salivation, involuntary urination, and convulsions 2. Dilated pupils and increased blood pressure and heart rate 3. Pinpoint pupils, decreased blood pressure, and increased heart rate 4. Rapid breathing and cold, clammy skin
A nurse delegates the ambulation of an older adult client to an unlicensed nursing assistant (UAP). Which statement should the nurse include when delegating this task?
a. "The client has skid-proof socks, so there is no need to use your gait belt." b. "Teach the client how to use the walker while you are ambulating up the hall." c. "Sit the client on the edge of the bed with legs dangling before ambulating." d. "Ask the client if pain medication is needed before you walk the client in the hall."