The purpose of the Glasgow Coma Scale is to
A) monitor neurologic problems.
B) measure intracranial pressure.
C) evaluate functional ability.
D) determine rehabilitation potential.
A
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The nurse is assessing a patient for altered immunocompetence. Which findings would indicate that the patient is at risk for developing an immunocompetence-associated illness?
1. Slow wound healing and easy bruising 2. Bursitis and muscle cramps 3. Heart palpitations 4. Heartburn and increased flatus 5. Mouth sores and oral patches
The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client's plan of care?
a. Administer a sedative medication. b. Ask a family member to stay with the client. c. Use restraints to prevent the client from falling. d. Place the client in a wheelchair at the nurses' station.
If the fire alarm sounds, which of the following is the first step in a sequence of emergency procedures?
A. Race to get the fire extinguisher. B. Activate 911 and the emergency team. C. Calmly remove all patients to a safe zone. D. Evacuate all staff members behind the fire doors.
Which action by the nurse is appropriate when selecting a cuff to accurately assess blood pressure (BP) on a child?
1. Select based on the label—infant, child, adult. 2. Select based on a bladder that covers two thirds of the upper arm and wraps around at least 80% of the arm circumference. 3. Select based on availability. 4. Select based on a bladder that covers one fourth of the arm circumference and 50% of the upper arm.