Which neurologic assessment technique does the nurse use to test a pt for sensory function?
a. touch the skin with a clean paper clip and as whether it is a sharp or dull sensation
b. ask the pt to elevate both arms off the bed and extend wrists and fingers
c. have the pt close the eyes and move the toes up or down; the pt identifies positions
d. have the pt sit with the legs dangling; use a reflex hammer to test reflex responses
Answer: a. touch the skin with a clean paper clip and as whether it is a sharp or dull sensation
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A female patient is concerned after learning that a person with whom she had a casual sexual encounter has been diagnosed as being HIV positive. Which other patient statement would the nurse evaluate as significant?
1. "I have not felt bad since the possible exposure." 2. "We were only together for about a week and had sex 3 or 4 times." 3. "I did have a cold and sore throat last week, but it has cleared up without problems." 4. "I had a normal period just a few days after we broke up."
Caring for the most intimate needs of ill persons requires that you operate within the personal space of each client. Every client has a sense of "space" in which the client feels comfortable; this space can be defined as:
1. a space around each person that the person does not wish another to enter. 2. an area about 50 × 80 square feet, in Western culture. 3. the physical area surrounding the person, emotional possession of the body, and personal self-knowledge. 4. the physical area surrounding the person.
A client is admitted to a nursing unit in acute alcoholic withdrawal. Which nursing diagnosis is the highest priority early in this admission?
a. Risk for injury related to disorientation and seizure activity b. Disturbed thought processes due to symptoms of withdrawal c. Imbalanced nutrition: less than body requirements due to poor intake d. Acute constipation related to effects of poor nutrition and decreased activity
Individualize map to obtain specific patient goals and outcomes
A. Assessment B. Implementation C. Planning D. Evaluation