The nurse is caring for a client with a neurosensory disorder, and directs care toward the most important priority of:
1. Minimizing complications.
2. Maintaining airway and supporting breathing.
3. Encouraging maximum independence.
4. Repositioning to prevent alterations in skin integrity.
2
Rationale: All of these focuses of care are important, but the greatest priority, according to the ABCs of nursing, is maintaining airway and supporting breathing. Damage to vital areas of the brain can result in reduced respiratory stimulation, so apnea is a very real possibility.
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A 78-year-old woman slipped and fell on an ice-covered sidewalk. The nurse would be most concerned that the patient has an unstable pelvic fracture if which assessment finding is present?
1. The patient fell directly on her coccyx. 2. The patient was incontinent of urine at the time of the fall. 3. The patient has bruising across her labia. 4. The patient complains of sharp pain just above her waist on the right side.
What is the benefit of antitrust laws to the health care consumer?
1. They prevent physicians from ordering unnecessary tests. 2. They promote the use of registered nurses rather than unlicensed assistive personnel. 3. They encourage activities to promote health. 4. They promote competition and efficiency in health care.
Which client situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor?
a. A primigravida who is 17 years old b. A 22-year-old multiparous client with ruptured membranes c. A primigravida who has requested no analgesia during her labor d. A multiparous client at 39 weeks of gestation who is expecting twins
The nurse is caring for an active 14-year-old boy who has recently been diagnosed with scoliosis. He is dismayed that a "jock" like himself could have this condition, and is afraid it will impact his spot on the water polo team
Which response by the nurse would best address the boy's concerns? A) "If you wear your brace properly, you may not need surgery." B) "The good news is that you have very minimal curvature of your spine." C) "Let's talk to another boy with scoliosis, who is winning trophies for his swim team." D) "Let's talk to the doctor about your treatment options."