The nurse recognizes a need to make a focused bowel assessment when the 80-year-old resident complains of:
a. the inability to have a bowel movement every day.
b. feeling pressure and fullness in the rectum, but is unable to defecate.
c. having had one loose stool after breakfast.
d. ingestion and flatulence.
ANS: B
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A patient comes to urgent care with a swollen, painful ankle. While the patient is waiting to be seen by the physician, a nurse could appropriately
1. Apply a cold pack to the ankle to reduce pain and edema. 2. Apply a hot pack to the ankle to improve mobility and promote healing. 3. Confirm that there are standing orders to apply ice to recent, localized joint injuries. 4. Confirm that there are standing orders to apply heat to recent, localized injuries involving edema.
The nurse reporting on duty learns that the nursing unit is using the AVPU scale on one of the nurse's assigned clients. The nurse recalls that the AVPU scale is used for:
a. determining the level of pain of an intubated child b. measuring the weight of a child who cannot stand c. obtaining a measure of the level of consciousness d. obtaining a gross measure of intracranial pressure
Which of the following are identified as psychoneurotic responses to severe anxiety as they appear in the DSM-5?
A. Somatic symptom disorders B. Grief responses C. Psychosis D. Bipolar disorder
A resident is vomiting. You need to do which of the following?
a. Follow Standard Precautions and the Bloodborne Pathogen Standard. b. Offer the person a carbonated beverage. c. Prevent aspiration by lying the person flat on his bed. d. Dispose of vomitus immediately in the trash can.