A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face. How does the nurse interpret these actions?
a. Poor left-sided motor control
b. Paralysis or contractures on the right side
c. Limited visual perception of the left fields
d. Unawareness of the existence of her left side
D
Clients who have experienced a right hemisphere stroke often have neglect syndrome, in which they are unaware of the existence of the paralyzed side, or the left side. This injury would not have an effect on the client's sight. This is not related to poor motor control or paralysis.
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The nurse is changing the dressing on self-inflicted cigarette burns on a patient with borderline personality disorder. When providing the care, which action by the nurse would be most thera-peutic?
a. Perform the actions while being nurturing and caring to keep patient from feeling abandoned. b. Approach the interventions with a mat-ter-of-fact demeanor to decrease second-ary gains of sympathy. c. Present a stern attitude to underscore the seriousness of the act. d. Interact in a professional and distant manner to diminish the opportunity for manipulation.
A client is receiving preoperative teaching. Which of the following can the client reasonably anticipate that the preoperative nurse will provide?
1. Teaching regarding pain control in the postanesthesia recovery room (PACU) 2. Teaching regarding the type of IV pump the client will have if he or she is discharged to home health 3. Teaching regarding client medications upon discharge 4. Teaching regarding the call lights and bed controls for the medical surgical unit
Sterile technique is not necessary when
1. Inserting a catheter into the bladder (hospital setting). 2. Taking standard precautions. 3. Inserting an intravenous (IV) needle into the vein. 4. Injecting medications into subcutaneous tissue.
Which of the following is an example of a health promotion activity?
A) Immunizations for 2 year olds B) Blood pressure screening at the senior center C) Pregnancy testing and counseling D) No smoking policies in the workplace