The nurse assessing the level of consciousness in a patient will do the following (arrange in order, from the simplest to the most complex):
1. Apply pressure to the nailbed.
2. Shake patient.
3. Touch the patient.
4. Call the patient's name.
5. Approach the patient.
5, 4, 3, 2, 1
The assessment begins with simply approaching the patient and progresses to imposing painful stimuli.
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A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.
A nurse is using the function-focused care approach to care for a hospitalized older adult. The nurse is assisting the patient to transfer from the bed to a chair
Which of the following statements by the nurse is most congruent with this approach to care? a. "Place your hands across your chest and let us move you to the edge of the bed." b. "Place both of your hands on the overbed trapeze and pull yourself up to a sitting position." c. "How do you get yourself out of bed when you are at home? Why can't you do the same thing here?" d. "It is taking you a long time to get your-self into a sitting position. Let me help you sit up."
An older adult patient is hospitalized for after an automobile crash. The nurse recognizes symptoms suggestive of an upper urinary tract (UTI) infection when the patient
a. voids 100 mL of urine over a 3-hour pe-riod of time. b. is not able to state where he is or what day it is. c. has an elevated red blood cell (RBC) count. d. reports burning when he urinates.
The nurse runs into a co-worker whose family friend is a patient on the unit. The co-worker asks about the friend's health problems. Which is the correct response by the nurse?
a. "Your friend told us to say nothing.". b. "Why don't you ask your friend now?" c. "You know I can't talk about the pa-tients.". d. "Well, it was really a very difficult sur-gery.".