A client, aged 75 years, has come to the clinic with a report of frequent headaches. Immediately after
introducing herself to the client at the outset of the interview, the nurse should
a. ask if the client if can hear clearly as she speaks.
b. initiate a neurological assessment to determine risk for stroke.
c. obtain a medication order for the client's headache.
d. suggest that the client lie down in a darkened room for a few minutes.
A
Before proceeding with any further assessment, the nurse should assess the client's ability to hear
questions. Impaired hearing could lead to inaccurate answers.
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As a community health nurse, you overhear a colleague say, "I don't understand why the Yangs take their young teenage daughters to the Hmong New Year celebration and have them play these matchmaking games
The girls meet boys every day as school and they are too young to be looking for husbands." Which of the following would be the most appropriate response? A) "The Yangs are very different from us; maybe in time we can convince them that their practices are not right." B) "Every culture has its differences; I think it's valuable that the Yangs are keeping their cultural practices alive." C) "I know what you mean, I was thinking the same thing. You wouldn't catch me doing something similar with my teens." D) "I feel sorry for those girls; they must feel funny in those cultural costumes. Let's talk to the parents and tell them how teens in America feel about such things."
A patient has stepped on a rusty nail and is exhibiting signs of muscle rigidity and contractions. The patient's wife called the emergency department (ED) and the triage nurse told her to bring him in
The ED nurse will have which drug available for administration when the patient arrives? A) Carisoprodol (Soma) B) Cyclobenzaprine (Flexeril) C) Metaxalone (Skelaxin) D) Methocarbamol (Robaxin)
The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). What should the nurse identify as being the primary focus of care for this patient?
1. respiratory support as the muscles of breathing fail, and managing secretions due to the inability to swallow and communication 2. providing gastrostomy feedings as soon as possible so as to build up muscle mass when motor functions return 3. pain management and active range-of-motion (ROM) exercises 4. giving immunosuppressants
Which one of the following examples of nursing actions would be considered an ethical/legal skill?
A) A nurse helps a patient prepare a living will. B) A nurse obtains a urine sample for a urinalysis. C) A nurse explains the rationale for a patient's plan of care. D) A nurse holds the hand of a woman whose baby died in childbirth.