The nurse is using Gordon's 11 categories for data collection in performing a health assessment. Which of the following represents assessment of cognition?
a. How educated is the patient?
b. How does the patient describe his or her health?
c. Is the patient well nourished?
d. Has the patient had treatment for emotional problems?
ANS: A
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An elderly patient has been admitted to the hospital for pneumonia. Which factor could put this patient at risk for a pressure ulcer?
a. A diet low in protein b. Braden Scale results of 22 c. Primary health care provider orders that read "activity as tolerated" d. Being repositioned every 2 hours
A nurse has delegated the collection of vital signs, including blood pressure readings, to two unlicensed assistive personnel. What is the nurse's responsibility for the delegated care?
1. The nurse is accountable for the care that was delegated. 2. The nurse is not responsible for these vital signs. 3. The nurse is not accountable for these vital signs. 4. The nurse is responsible for re-measuring all the vital signs.
A new mother and her partner are concerned about their infant's ability to respond to germs that will be present in different settings that they will visit with the baby after discharge
The nurse informs them that the infant has some protection from the maternal immunoglobulins that have crossed the placenta, known as Immunoglobulin E (IgE). A) True B) False
How would you manage this patient? Provide rationales for your actions
You are caring for a 68-year-old man who has had bilateral inguinal hernia repairs under a spinal blockade with sedation. His preoperative BP was 120/80 mmHg and his BP on arrival into the PACU was 105/85 mmHg. Your second blood pressure reading shows that his BP has fallen to 85/68 mmHg. What will be an ideal response?