When admitting a patient to the hospital, the nurse asks if has problems eating since the patient had a stroke. The patient denies any problems and states that does not require assistance
After lunch, the nurse notes that the patient has not eaten most of the food and has spilled much of the food. These cues lead the nurse to believe that the patient is not functioning at the level indicated upon admission. The nurse is using which type of information to make this deduction? a. Verbal behavior
b. Physical assessment
c. Nursing diagnosis
d. Nonverbal behavior
D
Observation of the level of function is different from what a nurse learns about function during the interview. A nurse observes what the patient does, such as self-feeding or making a decision, rather than what the patient says he or she can do. The level of function involves a person's ability to perform during everyday activities. Observation of the patient's behavior for level of function differs from a physical assessment. The hands-on physical examination measures the extent of function through measures such as range of motion and muscle strength. Verbal behavior is what the patient says. A nursing diagnosis would be self-care deficit.
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The nurse is caring for a patient with a substance use disorder who is addicted to heroin. The nurse understands that areas of the brain and nervous system have been connected to substance abuse and addiction
What is true regarding the nervous system and substance abuse and addiction? Select all that apply. 1. Changes in neuroanatomy cause the behavior seen in addiction. 2. Addictive substances act on the mesolimbic system of the brain. 3. Addictive substances stimulate surges of dopamine. 4. Addictive substances act on the mesocerebral system of the brain. 5. Changes in neurochemistry cause behaviors seen in addiction.
In the acute phase of care of a spinal cord injury client, the nursing assessment focuses on which of these critical factors first?
a. airway c. circulation b. breathing d. disability
While the nurse measures vital signs with the client in a standing position, the client complains of dizziness. What is the nurse's priority intervention?
1. Call for immediate assistance. 2. Help the client to lie on the floor. 3. Help the client to a seated position. 4. Inform client that dizziness will pass.