The nurse is assessing a patient who experienced a cerebrovascular accident (CVA) 24 hours ago. The patient does not have a gag reflex. Which conclusions by the nurse are appropriate based on this data? Select all that apply
1) Damage to cranial nerve IX
2) Damage to cranial nerve X
3) Risk for aspiration
4) Potential malignancy
5) Herpes simplex virus
ANS: 1, 2, 3
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The nurse is caring for a patient who has just had a radical mastectomy and axillary node dissection. When doing patient education, what should be included regarding hand and arm care of the affected side?
A) Avoid exercise of the arm. B) Keep cuticles clipped. C) Avoid lifting objects greater than 10 pounds. D) Use a sunscreen with an SPF of 4 to 8.
The Newborns' and Mothers' Health Protection Act of 1996 requires that all health care plans allow for a minimum length of stay following a normal vaginal birth of which of the following?
1. 24 hours 2. 36 hours 3. 48 hours 4. 96 hours
The community health nurse is trying to locate information about median household income, specifically the percentage of households below poverty level in the community. Which is the best source for these data?
A) Census records B) Chamber of commerce C) Department of Labor D) Local union office
The nurse caring for clients in a long-term nursing home assesses the clients for sensory deficits. Which of the following is a nursing care measure for this population?
A) Teach clients to clean their eyeglasses with a tissue or paper towel. B) Double the illumination for each added 13 years of age beyond 40. C) Do not keep a night light in the bathroom to stimulate the use of night vision. D) Tell the client not to let people know if speech is not heard.