The new graduate nurse is assessing a client with an unrepaired abdominal aortic aneurysm. What assessment technique requires further education by the supervising nurse?
a. Measurement of abdominal girth
b. Observation of abdominal wall movement
c. Auscultation of any area of the abdomen
d. Palpation of the abdominal midline area
D
Palpation on or near an aneurysm may cause pain and potential rupture. Observation, auscultation, and measurement are appropriate assessments.
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A recent nursing graduate is aware that the nursing scope of practice goes far beyond what is characterized as "bedside care." Which of the following is a nurse's primary responsibility?
A) To promote activities that enhance community cohesion B) To encourage individuals' self-awareness C) To promote activities that foster well-being D) To influence individuals' social interactions
The nurse and student nurse are observing a cardioversion procedure completed by a physician. At which time is the nurse most correct to identify to the student when the electrical current will be initiated?
A) During stimulation of the SA node B) During repolarization of the heart C) During ventricular depolarization D) During the QRS complex
How does memantine (Namenda) work for treatment of Alzheimer's disease?
a. Protecting the neurons from the changes that occur with Alzheimer's disease b. Blocking the enzyme that breaks down the neurotransmitter at the neuron synapses c. Blocking the amino acid glutamate at the N-methyl-D-aspartate receptors in the brain d. Increasing the amount of white matter surrounding neurons to prevent the formation of "tangles"
The nurse observes signs that a client may be experiencing dysfunction related to the vestibular branch of his acoustic nerve (CN VIII). In order to minimize the client's risk for injury, the nurse should:
1. Identify the client as a "fall risk.". 2. Assess the client's gag reflex prior to offering food or liquids. 3. Apply an "eye bubble" to the client at bedtime. 4. Assess the client's vision using a Snellen chart.