A nurse implements nursing measures to prevent neurological complications. The nurse knows the importance of which of the following? Select all that apply
1. Performing neurological checks as ordered
2. Keeping the room curtains closed
3. Assessing the patient's level of consciousness
4. Using a footboard or high-topped tennis shoes
5. Keeping a calendar and clock where the patient can see them
ANS: 1, 3, 4, 5
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The nurse suspects abuse when a 10-year-old child is taken to the urgent care center for a leg injury. The best way to document the history and physical findings is to:
a. Document what the child's caregiver tells the nurse. b. Use the words the child has said to describe how the injury occurred. c. Record what the nurse observes during the conversation. d. Rely on photographs of the injuries.
A patient has just been diagnosed with acute respiratory distress syndrome (ARDS). The nurse is aware that both acute lung injury (ALI) and ARDS patients often require which priority intervention?
1. Placement on a mechanical ventilator 2. Preparation of a living will 3. Frequent hydration with ice chips 4. Frequent suctioning to keep the airway clear
The nurse demonstrates understanding of continuity of care (COC) when doing which of the following?
a. Providing care in an untimely manner b. Utilizing management plans that are inconsistent c. Encouraging a longitudinal construct in health care d. Demonstrating inflexibility when managing the client's care
Terrence, a 42-year-old patient, presents with symptoms of chronic heart failure. His medical history reveals that he is allergic to ACEIs and administration of any ACEI to Terrence usually brings about a severe bout of angioedema. Which of the following drugs should be avoided?
A. Isosorbide dinitrate B. Hydralazine C. Captopril D. Nitroglycerine