Which condition may complicate the assessment of an older adult patient with a suspected head injury?
a. Sensory deficits
b. Slowed metabolism
c. Preexisting cerebral dysfunction
d. Decreased pulmonary function
A
Sensory deficits, circulatory disorders, and communication problems make it more difficult to assess an older adult patient with a suspected head injury.
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The nurse prepares the client with a terminal illness for a complete bath when the spouse suddenly arrives. The nurse will:
1. Begin bathing the client and ask the spouse to wait by the nurse's desk. 2. Ask the spouse to bathe the client so the nurse can care for another client. 3. Involve the spouse to the degree desired in bathing the client. 4. Instruct the spouse to sit in the chair at the client's bedside until the bath is completed.
A nurse is measuring the frequency of a laboring woman's contractions. How does the nurse accomplish this correctly?
A. Counts the number of contractions measured at the same intensity in 1 full minute B. Feels the fundus during the acme of the contraction and notes the fundal firmness C. Measures the beginning of one contraction to the beginning of the next contraction D. Measures the time from the beginning of one contraction to the end of the same contraction
A client's last menstrual period began on June 16 . Using Naegele's rule, the nurse calculates the client's estimated date of delivery (EDD) as:
a. March 9 c. March 23 b. April 23 d. April 6
The nurse is assessing a patient's pain. The patient is tearful, hesitant to move, and grimacing. When asked, the patient rates the pain as a two at this time using a zero-to-ten pain scale. What conclusion would be most accurate?
A) The patient has rated the pain as minimal according to the scale. B) The nurse should reinforce teaching about the pain scale number system. C) The nurse should reassess the pain in 30 minutes. D) The medication the patient is receiving is not adequate for pain relief.