The nurse is caring for a client who received spinal anesthesia. The client calls the nurse into the room, saying, "Come quick! I can't feel my legs!" The nurse's best response is:
1. "I will call the doctor immediately."
2. "Loss of feeling is normal, and will subside as the anesthesia wears off."
3. "Have you fallen or injured yourself in any way since surgery?"
4. "Did this occur suddenly, or have you noticed this ever since surgery?"
2
Rationale: Spinal anesthesia diminishes sensation below the level of the injection, and can completely eliminate sensation, depending on what medication is used and how much is administered. The nurse will reassure the client that the sensation loss is normal and temporary, and that he will regain full function within a few hours postoperatively. There is no need to notify the doctor or assess for injury.
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The nurse would know that a client who has just begun treatment for pulmonary TB with rifampin has a good understanding of this medication with the statement that
a. "I told my wife to throw away all our spoons and forks before I come home." b. "I won't go to any family gatherings for 6 months." c. "It's going to be important to remember to cover my nose when I sneeze." d. "My urine will look orange because of the medication."
The nurse notes that the skin around the client's skeletal traction pin site is swollen, red, and crusty, with dried drainage. What is the nurse's priority action?
A. Decrease the traction weight. B. Apply a new dressing. C. Document the finding as the only action. D. Notify the physician.
A nurse is preparing to administer a medication by using the vastus lateralis site and is unfamiliar with the process. A step-by-step reference that shows how to complete the process is called a:
a. deployment flowchart. b. top-down flowchart. c. Pareto chart. d. control plot.
Which communication technique will the nurse use more in crisis intervention than traditional counseling?
a. Role modeling b. Giving direction c. Information giving d. Empathic listening