The nurse conducting a physical examination is assessing a client's pupillary reactions. To do this correctly, the nurse would
a. ask the client to open the eyes and stare into the penlight.
b. ask the client to stare straight ahead and then turn on the penlight.
c. bring the penlight up from the client's chin to shine directly over the pupil.
d. bring the penlight in from the side to shine directly over the pupil.
D
The client is instructed to look straight ahead. To test direct response to light, the penlight is brought in from the side to shine directly over the center of pupil. Light should cause the iris to constrict, causing the pupil to become smaller.
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What will be an ideal response?
A patient with multiple injuries from a motor vehicle accident was recently moved into a semiprivate room in an acute rehabilitative unit (ARU) away from the main campus of the hospital
Three days after the move, the patient developed a cardiac complication and was in need of intravenous medications and cardiac monitoring. In order for the patient to receive the care that he needs, the nurse will A) move the patient into a private room in the ARU and begin the intravenous medications and cardiac monitoring. B) ask the family to provide a private nurse to administer the IV medications and monitor cardiac function. C) prepare for the patient to be transferred into the acute care hospital. D) start intravenous fluids and connect the patient to the cardiac monitor in the patient's room.
A nurse is educating an older adult with diabetes mellitus on minimizing the risk of cardiovascu-lar disease. The nurse focuses on lipid levels. Which of the following are the recommended goals for lipid levels? (Select all that apply.)
a. Cholesterol <200 b. Low-density lipoprotein (LDL) >100 c. High-density lipoprotein (HDL) >40 (men), >50 (women) d. Hb A1C value of ?6.5% e. Triglycerides <150
A patient in the prenatal clinic has backaches related to improper lifting and bending. The nurse demonstrates good body mechanics and explains how they can reduce back strain. This illustrates which step of the nursing process?
a. Assessment b. Diagnosis c. Planning d. Implementation