The nurse comes upon a motor vehicle accident with injury and stops to help. What should be the nurse's first action?
1. Assess the patient for bleeding.
2. Move the patient to a level surface.
3. Have someone take the patient's pulse.
4. Ask for permission to help.
4
Rationale: The nurse should first ask permission to help and should not force services if they are refused. Assessing the patient for bleeding and measuring vital signs as equipment is available are done only after permission to treat is obtained. The nurse would never move a patient unless the patient is in danger that is immediately life-threatening, like fire.
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The nurse who is providing care for an older adult patient who has dementia has read in the patient's chart that she has developed skin breakdown in her perineum as a result of urinary and fecal incontinence. The nurse knows to specifically assess:
A) The skin in and around the woman's gluteal crease B) The woman's labia majora and labia minora C) The woman's urethral meatus and the adjacent mucus membranes D) The area between the woman's vagina and rectum
A client is undergoing radiation therapy and asks the nurse about skin care for the exposed area. Which statement by the nurse is most accurate?
a. "No products work well to reduce the skin reactions you get from radiation." b. "No one product works best, so you can choose what you would like to use." c. "The only medication that works well for skin reactions is very expensive." d. "No good studies on skin care with radia-tion have been conducted to date."
A client is diagnosed with mild dementia while in the hospital. In preparing for discharge, what should the nurse should discuss with the family?
A) Possible need for home care B) Legal responsibility for the future C) Need for transfer to a long-term care facility D) Lack of free resources of care
When teaching clients about the newer, "atypical" antipsychotic medications, the nurse evaluates whether the clients have correctly learned that as a group these medications:
a. are not all alike in how they work and which side effects they produce b. are newer, more receptor-site-selective versions of the older "classical" antipsychotics c. are cheaper to purchase than the older "classical" antipsychotics d. are all virtually free of serious adverse effects when taken correctly