In assessing a woman for pain and discomfort management during labor, a nurse would most likely:
1. have the woman use a visual analog scale (VAS) to determine her level of pain.
2. note drowsiness as a sign the medications were working.
3. interpret a woman's fist clenching as an indication she is mad at her male partner and the doctor.
4. evaluate the woman's skin turgor to see whether she needs a gentle oil massage.
1
1. Correct. The VAS is a way to add the woman's assessment of her pain to the nurse's observations.
2. Incorrect. Drowsiness is a side effect of medications, not usually (sedatives aside) a sign of effectiveness.
3. Incorrect. The fist clenching is likely a sign of apprehension that may need attention.
4. Incorrect. Skin turgor along with moisture of membranes and concentration of urine are signs that help the nurse evaluate hydration.
You might also like to view...
Which patients should be assessed for nutritional deficiencies? (Select all that apply.)
a. Patient who scored a 13 on the mini-nutritional assessment b. Elderly patient on bed rest after surgery on the small intestines c. Patient receiving an IV of 5% dextrose d. School-aged patient with positive nitrogen balance e. Middle-age patient with rashes and easily pluckable hair
When caring for an intubated patient on mechanical ventilation using positive end-expiratory pressure (PEEP), the nurse continually assesses for which potential complication?
A) Lung injury due to barotraumas B) Pulmonary emboli C) Cor pulmonale D) Pulmonary edema
Which of the following would the nurse expect to assess in a client diagnosed with postpartum psychosis?
A) Loss of pleasure B) Failed reality testing C) Feelings of hopelessness D) Lack of energy
After teaching a class about family and domestic violence directed toward children as a community health problem, which of the following if stated by the class indicates to the instructor that the teaching was effective?
A) Family violence is new and occurs as a result of our fast-paced technological society. B) Family violence has occurred in most countries for centuries as children have been thought of as the property of their parents. C) Family violence occurs mostly in the urbanized areas of the United States mostly in the urbanized areas where exposure to crime is more prevalent. D) Family violence is decreasing in industrialized countries in the world as a result of more public awareness.