The nurse is responsible for maintaining intact skin for the compromised client. Appropriate nursing priorities include: Standard Text: Select all that apply
1. Checking pressure points regularly.
2. Regular turning and repositioning schedules.
3. Strict precautions to provide clean care to the wound.
4. Delegation to unlicensed assistive personnel.
5. Documenting care given.
1,2,5
Rationale: The nurse checks pressure points regularly.
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What are the criteria for the diagnosis of bulimia? (Select all that apply.)
a. Occasional episodes of binge eating b. Refusal to maintain body weight that is more than 15% below normal c. Excessive emphasis placed on body shape and weight d. Eating binges at least twice per week for at least 3 months
The spouse of a pregnant patient is quiet during prenatal visits but is demonstrating emotional involvement in the pregnancy. What action did the spouse perform?
A) States he definitely wants a girl B) Refuses to paint the baby's room blue C) States he is concerned about the loss of his free time D) Walks around furniture as if his abdomen is enlarged
The nurse is administering drugs to neonates and will consider which factor may contribute the most to drug toxicity?
a. The lungs are immature. b. The kidneys are small. c. The liver is not fully developed. d. Excretion of the drug occurs quickly.
The nurse wishes to test opposition ability in the patient's thumb. How would the nurse instruct the patient?
1. "Touch each one of your fingertips with your thumb.". 2. "Move your thumb across your palm away from the rest of your fingers.". 3. "Move your thumb across your palm and touch your fifth finger.". 4. "Move your thumb anteriorly away from the palm and then back.".