You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not confused prior to the being found on the floor. What is your first step in the nursing process in this situation?
A.
Leave the patient to get help.
B.
Gather more information by making observations about the patient.
C.
Call the patient's MD from your cell phone.
D.
Help the patient get up and then document your findings in the chart.
ANS: B
Being the first person on scene, you need to find out as much information as possible to report to the charge nurse as part of data collection. Never leave the patient alone until you are sure the patient is secure.
You might also like to view...
The nurse teaching a patient about ways to regain strength after a period of prolonged immobility advises the patient to seek assistance from a physical therapist
Which type of exercise is performed using specialized apparatuses that use resistance at a constant, preset speed? a. Isokinetic b. Isometric c. Isotonic d. Isomorphic
The mother of a child diagnosed with attention-deficit syndrome receives a prescription for a central nervous system (CNS) stimulant to treat her child
The mother asks the nurse, "I don't understand why we're giving a stimulant to calm him down?" What is the nurse's best response to this mother? A) "It helps the reticular activating system (RAS), a part of the brain, to be more selective in response to incoming stimuli." B) "It helps energize the child so they use up all of their available energy and then they can focus on quieter stimuli." C) "No one truly understands why it works but it has been demonstrated to be very effective in treating ADHD." D) "The drugs work really well and you will see a tremendous change in your child within a few weeks without any other treatment."
The nurse is aware that a patient with osteomalacia who is being treated with vitamin D supplements may be at risk for which of the following?
A) Hypercalcemia B) Hypernatremia C) Hypermagnesemia D) Hyperchloremia
Discuss nursing management of a client undergoing a bone scan
a. What are some of the factors and disease processes that affect bone formation and density?