When assessing the integrity of a patient's skin, the nurse is
1. Checking the elasticity of the skin.
2. Looking for cuts or breaks in the skin.
3. Assessing the color of the skin.
4. Determining whether the skin is moist or dry.
ANS: 2
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Establishing short- and long-term goals to address nursing diagnoses involves: (Select all that apply.)
a. discussion with the patient. b. exclusion of family with making patient decisions. c. collaboration with other members of health care team. d. making the health care provider as the central figure. e. coordination of care as collaborative care.
How should the nurse proceed when caring for a suit-prone patient?
1. Give the same compassionate, competent care that all patients receive. 2. Treat the patient in the same rude and hostile manner the patient uses. 3. Avoid the patient if possible so that there will be less chance of saying the wrong thing or performing in an incompetent manner. 4. Assign the patient to a different nurse each shift, so that only one nurse will become the target of a lawsuit.
You should always assume that a person who is comatose can:
a. Hear b. See c. Touch d. Speak
The nurse is transferring the client who is able to provide minimal assistance from the bed to the wheelchair. Which nursing action will provide for the safest transfer for this client?
1. Raising the bed height to waist height 2. Placing the wheelchair on the client's strong side 3. Placing the wheelchair with the feet pointing toward the side of the bed 4. Locking the wheels of the wheelchair and lowering the footplate