The nurse palpates the client's jaw movement, placing two fingers in front of each ear and asking the client to slowly open and close the mouth. The nurse also asks the client to:
a. Move the jaw side to side.
b. Swallow.
c. Smile.
d. Clench the teeth together.
ANS: A
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A nurse is overheard by a family member of a client discussing the condition of the client. This nurse is in violation of the:
a. Client's informed consent b. Right to competent care c. Americans With Disabilities Act d. Health Insurance Portability and Accountability Act
A nurse is conducting a screening program for autism in infants and children. Which of the following would the nurse identify as a warning sign?
A) Lack of babbling by 6 months B) Inability to say a single word by 16 months C) Lack of gestures by 8 months D) Inability to use two words by 18 months
A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?
a. Assist the patient to splint the chest when coughing. b. Teach the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.
Mrs Tagaloa is at potential risk for unintentionally retained surgical items. What factors contribute to her being at additional risk, and what can be done to prevent harm?
Mrs Lanuola Tagaloa is a 54-year-old Samoan woman who has lived in Australia for the past 15 years. She was admitted on the day of surgery for an elective vaginal hysterectomy with anterior/posterior colporrhaphy. She has a history of asthma and has type 2 diabetes mellitus (diagnosed at 42 years of age). Mrs Tagaloa has a history of grand multipara. She has a BMI of 30+ and falls into the obese category, but appears otherwise fit and well. She lives at home with her extended family and is responsible for the care of her mother and school-aged children. The admissions nurse informs you that Mrs Tagaloa is very softly spoken and did not maintain eye contact. She was accompanied by a female family member and overheard to be conversing in her native language. What will be an ideal response?