A patient was restrained after assaulting a staff member. Which nursing measure has priority?
a. Monitor the patient every 30 minutes.
b. Maintain constant supervision of the patient.
c. Administer a sedating medication after applying the restraints.
d. Distract the patient at frequent intervals while restraints are in use.
B
Restrained patients must be constantly observed, with documentation of physical safety and comfort interventions occurring at 15-minute intervals. Medication may be administered, but this is not the priority action. Distraction is not an effective technique to use when a patient is in restraints, because minimal stimulation is preferred.
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The nurse working in the Emergency Department admits a woman who states she has been raped. The nurse's priority of care includes:
1. Assist the woman to bathe to remove the dirty feeling she reports. 2. Have the woman tested for blood alcohol level. 3. Provide emotional support. 4. Ask the woman to explain exactly what happened.
Which of the following pathophysiological processes would a clinician most likely expect in a client with a diagnosis of dementia rather than delirium?
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The nurse has been invited to present a program at the local parent-teacher association (PTA) meeting on recognizing and preventing illness in children. Which symptoms of urinary tract infections in preschool age children should the nurse include?
Select all that apply. A) Urinary urgency B) Elevated blood pressure C) Dysuria D) Fever E) Headache
Which statements are correct concerning vaccines and toxoids? (Select all that apply.)
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