The nurse uses which of the following alternatives to restraints when ever possible: Standard Text: Select all that apply
1. Place clients who are at risk for falls in an area that is constantly supervised
2. Lock the wheels on the clients wheelchair
3. Use environmental restraints
4. Use rocking chairs to expend energy
5. Monitor client medications
1,3,4,5
Rationale 1: Supervision is an appropriate intervention.
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When a client has undergone a carotid endarterectomy and has been returned to the nursing unit with stable vital signs, the nurse should
a. assess neurologic status every 4 hours. b. keep the client in a flat, supine position with the head flexed. c. maintain blood pressure within 20 mm Hg of the preoperative values. d. provide neck range-of-motion exercises every 8 hours.
When performing a complete pain assessment, which of the following data indicate assessment of pain in the affective domain?
1. "This pain is punishment for my misdeeds.". 2. "The pain is a 9 on a scale of 1 to 10.". 3. "The pain comes in waves in my abdomen.". 4. "The patient is pale and moaning.".
A home health nurse is visiting with patients for the day. Most of the patients are elderly people, being cared for in their home by family members. As part of a cultural assessment, the nurse must also discuss
A. Caregiver stress and burnout B. Financial responsibilities C. Mental status changes D. Expected needs over the coming year
What does the student learn about warm autoimmune hemolytic anemia?
a. Warm autoimmune hemolytic anemia occurs primarily in children. b. It is self-limiting and rarely produces hemolysis. c. Erythrocytes are bound to macrophages and sequestered in the spleen. d. Immunoglobulin M coats erythrocytes and binds them to receptors on monocytes