A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation?
A. Provide warm milk and a backrub.
B. Give a sleep medication.
C. Hold a relaxation group before bedtime.
D. Review the client's normal sleep pattern.
D
In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation the nurse must initially determine the client's normal sleep patterns in order to evaluate if a true problem exists.
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MC Most drugs are metabolized in which body area?
A. Kidney B. Plasma C. Liver D. Intestinal mucosa
The nurse is grading muscle strength during an assessment. The nurse should document strength of the arms as a 3 if:
1. the client could perform full range of motion (ROM) against full resistance. 2. the client could maintain ROM against gravity. 3. the nurse could feel contraction when there was no movement. 4. the client could perform full ROM against moderate resistance.
While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?
A) Myopia B) Presbyopia C) Direct reaction D) Consensual reaction
Your client has a pressure ulcer. This is an example of what type of wound?
1. chronic, open, possibly contaminated 2. closed, contaminated 3. clean, closed, laceration 4. chronic, penetrating, contaminated