The primary rationale for why a nurse moves a client slowly from a sitting to a standing position is because of the potential for:
A. Fatigue
B. Muscle injury
C. Sensory disorientation
D. Orthostatic hypotension
D
A, B, C, and D. A client who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop in blood pressure) when transferred.
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The nurse is helping in discharge planning of a client who needs extensive rehabilitation and who is on a complicated medication schedule. The nurse would want to include which of the following in this client's plan?
A) Pharmacist B) Physician C) Social worker D) Client's spouse
After a 5 percent acetic acid wash is applied to the cervix, the cervix blanches white. Based on this data, which conclusion by the nurse is appropriate?
1) Bacterial vaginosis 2) Monilial vaginitis 3) HPV 4) Cervical cancer
Which of the following would be the best example of a short-term safety goal for a client who recently experienced abdominal surgery?
1. The client will show no systemic or local signs of infection by time of discharge from hospital. 2. The client will demonstrate an understanding of the proper use of pa-tient-controlled analgesia (PCA). 3. The client will demonstrate effective coughing and deep-breathing techniques within 2 hours of surgery. 4. The client will consistently use the call bell to notify the staff of a need for assis-tance to the bathroom upon return to the nursing unit.
A client presents in the Emergency Department with hallucinations, anxiety, and confusion. The client denies taking any illegal drugs in the past 48 hours. Based upon the assessment data, the nurse is aware that these symptoms can occur from which type of drug?
1. Hallucinogens 2. Barbiturates 3. Cannabinoids 4. Opioids