The nurse delegates applying a binder over the client's abdominal incision to the nursing assistant. Which does the nurse include in the nursing assistant's instructions?
1. Start the binder right under the axilla.
2. Place client in semi-Fowler's position.
3. Secure the binder with metal fasteners.
4. Remove old dressing and apply binder.
3
3. The nurse instructs the nursing assistant to secure the binder with metal fasteners, Velcro strips, or safety pins to keep the dressing in place; the nurse wants to avoid the binder from accidentally opening and increasing the risk of client infection.
1. If the assistant starts right under the axilla, the binder will encase the thorax, po-tentially impairing the client's ability to oxygenate, ventilate, cough, and deep breathe and thus increase the risk of hypoxia, acidosis, atelectasis, and pneumonia.
2. The nurse instructs the assistant to place the client in the supine position to apply the binder because, in that position, the client assists the assistant by rolling from side to side. This allows the assistant to place the fan-folded binder under the client so the assistant can get the binder around the abdomen.
4. The nurse instructs the assistant to apply the binder after the nurse completes the sterile dressing change to prevent client infection and to protect the wound.
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The nurse is providing discharge instructions to a client diagnosed with an anxiety disorder. What will the nurse tell the client about the activity of the amino acid gamma-aminobutyric acid (GABA), benzodiazepines, and the effect on anxiety?
1. GABA is an inhibitory neurotransmitter. 2. GABA increases neuronal excitability. 3. GABA increases can be neurotoxic. 4. GABA is an excitatory neurotransmitter.
The daughter of an elderly client reports that the client is experiencing a decrease in hearing ability in the client's right ear. The nurse suspects a conductive hearing loss due to the presence of dried wax in the right ear canal
In which of the following ways can the nurse best validate this suspicion? 1. Perform the Weber test. 2. Perform the Rinne test. 3. Examine the external ear. 4. Perform the whisper test.
The client is taking acetaminophen on a regular basis as well as oral contraceptives. The nurse tells the client that this drug interaction will result in a(n) _____ in the effectiveness of the _____
a. decrease; oral contraceptives b. increase; oral contraceptives c. decrease; acetaminophen d. increase; acetaminophen
A group of nursing students is reviewing information about other psychotic disorders. The students demonstrate a need for additional review when they identify which of the following about schizophreniform disorder?
A) The duration of the illness is usually less than 6 months. B) Symptoms must be present for at least 1 month for the diagnosis. C) The majority of individuals with the disorder recover completely. D) The individual experiences hallucinations and/or delusions.