The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter
What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing.
b. The patient is exhibiting flexion posturing.
c. The patient is exhibiting purposeful movement.
d. The patient is withdrawing to stimulation.
C
This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.
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A client is brought to the emergency department, does not speak English, and needs to have an emergency surgical procedure. The hospital has an interpreter available to explain the procedure and help with the consent form
When the interpreter arrives, the staff should make sure that: 1. The interpreter uses words the client is familiar with for the best understanding. 2. They ask the interpreter to translate as closely as possible the same words used by the professional staff. 3. The staff addresses the questions to the interpreter, so nothing is missed. 4. The client's family is included in the process and exchange of information.
What action by a nurse will help a patient meet self-esteem needs?
A) verbally negate the patient's negative self-perceptions B) freely give compliments to increase positive self-regard C) independently establish goals to improve self-esteem D) respect the patient's values and belief systems
The nurse has provided instructions to a client taking diazepam (Valium) for short-term anxiety. Which statement by the client indicates that the client needs additional instruction?
a. "I will avoid drinking alcohol while taking this drug." b. "I will continue to eat grapefruit while taking this drug." c. "I will avoid using heavy equipment when taking this drug." d. "I will contact the healthcare provider if I develop a rash."
These statements are about an older person's feet. Which is incorrect?
a. Nails become thick and tough. b. Feet usually have poor circulation. c. Serious infections can result from nicks or cuts. d. Deodorants are needed for foot odors.