During which stage of sleep would you expect your client's vital signs to be higher than while awake?
a. stage 1 non-rapid eye movement (NREM) sleep
b. stage 2 NREM sleep
c. stage 3 to 4 NREM sleep
d. rapid eye movement (REM) sleep
D
REM sleep usually occurs after about 90 minutes of NREM sleep; during this stage, electroencephalogram (EEG) patterns are similar to those of waking, heart and respiratory rates are irregular, muscles are flaccid, and eye movements are rapid and associated with dreaming. REM sleep periods become longer as sleep progresses and the person becomes more rested.
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The nurse knows that which of the following is not used to assess fall risk?
a. Glasgow Falls Scale b. Johns Hopkins Hospital Fall Assessment Tool c. Morse Fall Scale d. Hendrich II Fall Risk Model
Prior to administering bethanechol to a client, the nurse would assess which of the following? Select all that apply
A) Palpation of the bladder B) Palpation of the thyroid C) Blood glucose D) Blood pressure E) Pulse rate
A client is scheduled for a subtotal hysterectomy, which means that:
a. only the uterus will be removed b. the surgery will be performed through an abdominal incision to visualize the entire pelvic region c. the surgery will be performed with a laparoscopic approach d. the uterus, cervix, and fallopian tubes will be removed
After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the wrong medical record. What should the nurse do?
1. Use white-out over the mistake. 2. Take a wide permanent marker and blacken out all the documentation. 3. Put an "X" through the entire page, identify it as an "error," initial, and move on to the correct chart. 4. Draw a single line through the documentation, write "mistaken entry" next to the original entry, and initial it.