When monitoring the trauma client's nutritional status, which of the following data would be priority to assess?
1. Daily weights and presence of bowel sounds
2. Fluid-volume intake and food allergies
3. Ability to feed self and types of odor in the room
4. Family ability to assist with feedings and last documented bowel movement
Daily weights and presence of bowel sounds
Rationale: Assessment of daily weights, 24-hour caloric intake, and presence of bowel sounds, nausea and vomiting, or flatus are the objective priority data the nurse should assess with regard to nutritional status. Fluid volume is important but is usually very low in caloric intake and mainly prescribed for fluid and electrolyte balance. The ability to feed self may be assessing the client's neurological and musculoskeletal status. If the client requires rehabilitation, then family assistance may factor in at that point in the client's recovery.
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Self-protective responses are seen in behaviors that meet basic:
a. Goals b. Needs c. Wants d. Demands
The physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed?
1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 3) Obtain an order to restrain the client before inserting the urinary catheter. 4) Inform the physician that she cannot perform the procedure because the client is confused.
When information is reported by the patient, it is considered to be subjective data. Which statement below is considered to be objective data?
1. The patient tells the nurse, "I have pain in my lower back." 2. Mr. Williams tells the nurse he is having trouble catching his breath. 3. Miss Sims has told the doctor she has no history of allergies to antibiotics. 4. The patient's skin is warm and dry.
Which theory of pain proposes that pain can be relieved by blocking the transmission of pain impulses to the brain by physical modalities and altering the individual's thought processes, emotions, or other behaviors?
a. gate control theory c. perception modula-tion b. Kussmaul's theory d. transduction