When the nurse assesses the patient's abdominal superficial reflexes, the umbilicus moves in the direction of the skin stimulated. How would the nurse document this observation?
1. An absence of response
2. A questionable response
3. A negative (-) response
4. A present (+) response
4
Rationale 1: Moving in the direction of the skin being stimulated is a response.
Rationale 2: Responses are not documented as questionable.
Rationale 3: Superficial responses are not documented as positive or negative.
Rationale 4: Superficial reflexes are scored as either present (+) or absent (-). The umbilicus moving in the direction of the skin being stimulated is a (+) response.
You might also like to view...
The nurse is assessing a patient with chronic depression who admits to having grown increasingly despondent for the past 2 weeks; he attributes this to the likelihood of his business going bankrupt and his wife's recent filing for divorce
Which statements merit further evaluation as possible covert expressions of suicide ideation? Select all that apply. a. "I'm not sure what to do; I'm lost.". b. "I only see one way out of this.". c. "It will be better after tomorrow.". d. "I've never felt this bad before.". e. "I couldn't live without my kids.". f. "Thank you for all you've done.".
A patient is considered terminal after being involved in a motor vehicle accident in which they received massive trauma to the head
As the patient's ICP increases and condition worsens, the family asks you what indications of approaching death will there be. What would be your best response? A) "There is a change in the pattern of their respirations." B) "Projectile vomiting and hemiplegia usually occur just before death." C) "Posturing may develop as pressure on the brainstem increases." D) "Loss of brainstem reflexes is a sign of approaching death."
How does a qualitative historical researcher determine validity and reliability? The researcher:
a. determines that theoretical saturation is reached with as many primary sources as possible and secondary sources on a limited basis. b. does not need to be concerned with validity and reliability. c. finds as many sources as possible on the topic and does not exclude any of them. d. uses references written about the subject by qualified experts to help ensure validity and reliability.
Which of the following is a nitrate compound that is used therapeutically to relieve acute attacks of angina?
1. Quinidine sulfate 2. Nitroglycerin 3. Digitalis 4. Minoxidil