The nurse is assessing muscle strength in a fully conscious patient as part of a neurologic assessment. Which technique should the nurse employ?
a. Press down on the patient's extended arms one at a time while the patient attempts to raise the arm.
b. Apply pressure above the eye and push upward while the patient attempts to re-move the hand.
c. Pinch the trapezius muscle at the angle of the shoulder and neck while twisting the fingers slightly.
d. Rub the sternum with fisted knuckles in a twisting motion while the patient attempts to remove the fist.
A
To test muscle strength, have the patient extend her arms in front of her, and press down on each arm one at a time, while asking her to try to raise her arm. Applying pressure above the eye, pinching the trapezius muscle, or employing a sternal rub tests the degree of unconsciousness in a patient (and does not include asking the patient to attempt to remove the hand).
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A client has been prescribed amitriptyline (Elavil) for treatment of depression. The nurse teaches the client to avoid use of over-the-counter sleep aids. What is the nurse's rationale for this advice?
1. Using these drugs in combination often causes bradycardia. 2. Use of amitriptyline can change enzymatic action. 3. Amitriptyline also induces sleep, so additional sleep aids are not needed. 4. Using these two medications together decreases enzyme production in the pancreas, which results in pancreatitis.
Which actions by the nurse indicate compliance with the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)
a. The nurse posts an update about a client on Facebook. b. The nurse gives the report to the oncoming nurse in a private area. c. The nurse gives information about the client's status over the phone to the client's friend. d. The nurse logs off any computer screen showing client data before leaving the computer unattended. e. The nurse puts any documentation with the client's information in the shred bin at the hospital before leaving for the day.
A 29-year-old woman presents to the urgent care center with a history of a severe headache of 2 hours' duration. She describes it as bandlike and constricting. In interviewing the woman about her complaint, you would ask:
a. whether she has experienced increased tearfulness. b. the date of her last menstrual period. c. whether these headaches started in child-hood. d. whether she is particularly stressed or overworked.
Bradypnea may accompany:
a. a subconscious response to observation. b. an excellent level of cardiovascular fitness. c. ascites. d. severe pain from a rib fracture.