To assess a cremasteric reflex, the nurse strokes the:
a. sole of the foot and observes whether the toes fan down and out.
b. abdomen and observes whether the umbi-licus moves away from the stimulus.
c. inner thigh and observes whether the tes-ticle and scrotum rise on the stroked side.
d. palm and observes whether the fingers attempt to grasp.
C
Stroking the inner thigh of a male patient (proximal to distal) will elicit the cremasteric reflex. The testicle and scrotum rise on the stroked side. Stroking the sole of the foot elicits a Babinski sign. Stroking the abdomen elicits an abdominal reflex. Stroking the palm elicits a palmar grasp.
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The patient informs the nurse that his preference for having his eldest son make all his health care decisions is a cultural practice. How should the nurse respond?
A) Ask the son to allow the patient to make his own health care decisions. B) Explain to the patient that he is responsible for his own decisions. C) Work with the team to negotiate informed consent. D) Refuse to divulge any information to the eldest son.
A nurse is caring for a 34-year-old patient admitted with severe diarrhea that has been going on for 2 weeks. What assessment should the nurse anticipate?
a. Edema of lower legs and feet b. Hypotension and fatigue c. Hypertension and hunger d. Metabolic alkalosis
The parents of a 10-year-old child being admitted to the children's behavioral unit ask the nurse what a therapeutic milieu is. What is the nurse's best answer?
A) "The dayroom on our unit" B) "The school room on our unit" C) "A safe and secure structured environment" D) "A place where the client and the patients can interact"
When the CAGE questionnaire is used to guide the assessment of alcohol misuse, the nurse would ask which questions?
1. Have you ever crashed overnight in an unfamiliar area, arrived late for work, given up family and friends, or escaped arrest by the law? 2. Have you ever felt the need to cut down on drinking, felt annoyed by criticism of your drinking, ever had guilty feelings about your drinking, or ever had an eye opener first thing in the morning to get rid of a hangover? 3. Have you ever had a big crisis that led to arrest and grief from your family and friends and tried to explain away your actions? 4. Have you called off or were absent from work because you had too much to drink and needed to sleep it off?