The nurse asks the client to hold the arms straight out, perpendicular to the floor, and the nurse tries to push the client's arms down. The nurse is testing the strength of which muscles in this procedure?
a. Triceps
b. Biceps
c. Trapezius
d. Deltoid
ANS: D
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A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)
a. Allow the client to assume a position of comfort. b. Allow the client's family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy.
A patient and family have the nursing diagnosis of impaired verbal communication secondary to a language barrier. What action by the patient/family would best indicate that short-term goals for this diagnosis have been met?
A. Able to communicate long-term desires for health of the patient B. Demonstrates comprehension by head nodding and saying "yes" C. States understanding of condition and treatment via an interpreter D. Understands how nonverbal communication varies between cultures
Which of the following is a true statement about documentation?
a. Nurses should keep records of patients' wishes. b. Patients do not have access to their own medical records. c. The OASIS is a complete record of the health status of a patient. d. The nurse is responsible for completing all of the Minimum Data Set (MDS).
Which observation indicates to you that the client is correctly using the technique of diaphragmatic breathing?
A. Abdomen rises on inhalation and remains elevated during exhalation B. Abdomen falls on inhalation and remains low during exhalation C. Abdomen falls on inhalation and rises on exhalation D. Abdomen rises on inhalation and falls on exhalation