Which of the following may a nursing assistant be responsible for determining?
a. Vital signs
b. Cranial nerve function
c. Neck vein distention
d. Auscultation of bowel sounds
A
Assistive personnel can be trained to count apical pulse and peripheral pulses after the nurse's initial assessment. Assistive personnel need to be instructed to recognize temperature and color changes, along with changes in peripheral pulses. Comprehensive heart and neck vessel assessment should not be delegated to assistive personnel. However, assistive personnel should know to report the development of abdominal pain or changes in the patient's bowel habits or dietary intake.
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The nurse caring for the child should assure the mother that this is a normal response for a child who has undergone surgery, and that it is a coping mechanism that children use called: 1. Repression. 2. Rationalization. 3. Regression. 4. Fantasy.
The nurse is assessing a client scheduled for reconstructive surgery when the client states, "I can't wait to have this procedure done. I'm going to have a wonderful life once my appearance is improved
" The nurse interprets this comment as an indication that the client: 1. Is excited about how the surgery will improve his life. 2. Recognizes the importance of physical appearance. 3. Has an unrealistic expectation. 4. Is attempting to reduce anxiety.
A client sustained a sprained ankle while skiing, and the physician ordered RICES. What will the nurse inform the client to do related to the physician's order upon discharge?
A) Rest, ice, compression, elevation, stabilization B) Rest, inflammation, compression, elevation, stabilization C) Rate the pain, increase activity, compression, elevation, stop skiing D) Range of motion, ice, circulation, elevation, steroids
The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests that they
a. stand rather than sit when performing household and yard chores. b. strengthen small hand muscles by wringing sponges or washcloths. c. protect the knee joints by sleeping with a small pillow under the knees. d. avoid activities that require repetitive use of the same muscles and joints.