When utilizing the Glasgow Coma Scale during an assessment, the nurse identifies that the client is making incomprehensible sounds. This assessment finding would be included in which part of the assessment?
1. Eye opening
2. Verbal response
3. Best motor response
4. Mentation
2
The assessment finding of incomprehensible sounds would be documented within the verbal response section of the Glasgow Coma Scale. Eye opening would assess if the client opens the eyes in response to stimuli. Best motor response would assess the stimuli needed to have the client move an extremity or body part. Mentation is not a category within the Glasgow Coma Scale.
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Which of the following nursing interventions is most appropriate when an evisceration occurs in the surgical wound of a client who has undergone surgery?
A) Instruct the client to avoid any movement. B) Administer prescribed analgesics. C) Place the client in a position that puts the least strain on the operative area. D) Place sterile dressings moistened with normal saline over the protruding organs and tissues.
The nurse is preparing to perform an evaluation of the older adult client's level of cognitive reasoning. The student nurse is observing. Which of the following statements by the student nurse indicates the need for further education?
1. "The Mini–Mental State Examination seems like a quick way to determine how well the client is able to reason.". 2. "It's best to go ahead and give the Mini–Mental State Examination at the beginning of the focused interview because the client's mind will be fresh.". 3. "It sounds like some older people get really nervous about these cognitive reasoning examinations because they worry they may be developing problems.". 4. "The Mini–Mental State Examination is really easy to perform so it's important to remember that the client may have just gone through these types of questions the day before with another healthcare provider.".
During the assessment of a preschool-age child, the nurse notes that the child's tongue is tender and there are cracks in the corners of the child's mouth. Which vitamin deficiency does the nurse suspect this child is experiencing?
A) Vitamin A B) Vitamin B1 C) Vitamin C D) Vitamin D
A patient is having financial issues. Which of the following variables would be affected in this patient's ability to adhere to a therapeutic regimen?
a. Demographic c. Treatment b. Financial d. Illness