The nurse is caring for a confused, combative patient. Which action would be considered last by the nurse to control behavior of the client?
a. Orient the patient frequently.
b. Apply restraints.
c. Move the patient to a room close to the nurse's station.
d. Encourage the family to spend time with the patient.
ANS: B
All alternatives to physical restraints should be considered prior to their use.
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A patient comes to you because she is experiencing a tremor only when she reaches for things. This becomes worse as she nears the “target.” When you ask her to hold out her hands, no tremor is apparent. What type of tremor does this most likely represent?
A) Intention tremor B) Postural tremor C) Resting tremor D) Nervous tremor
A resident is transferring to a different room. The nurse asks you to transfer the person. You can do which of the following?
a. Help the person pack. b. Transport the person to the new room. c. Discontinue all tubes and drains. d. Bring the person's chart, care plan, and drugs.
During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further?
a. Neurological deficit b. Visual deficit c. Hearing deficit d. Balance deficit
Twenty minutes after receiving a dose of antibiotic, the patient develops a red, itchy rash. What nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. The nurse should plan to watch for a rash after the next dose is administered. 2. The nurse should contact the prescriber and relay this assessment information. 3. The nurse should contact the pharmacy. 4. The nurse should place an allergy bracelet on the patient. 5. The nurse should document the presence of the rash in the medical record.