The nurse is performing a neurologic assessment on a newly admitted head injury patient. Which sign does the nurse recognize as that most indicative of a brainstem injury?
a. Nystagmus
b. Decerebrate posturing
c. Seizure activity
d. Glasgow Coma Scale score of 3
B
The appearance of decerebrate as well as decorticate posturing is an indicator of brainstem injury. Nystagmus, seizures, and a Glasgow score of 3 are not necessarily signs of brainstem injury.
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The nurse is providing health education to an 80-year-old woman who has just been diagnosed with osteoporosis. Which of the following represents an accurate statement when teaching her about this diagnosis?
A) "Osteoporosis is usually a result of a bone injury." B) "Osteoporosis causes a risk for fractures." C) "Osteoporosis results from nonmodifiable risk factors." D) "Osteoporosis occurs only in women."
When providing nursing to clients, the nurse demonstrates which of the following to minimize the risk of infection: Standard Text: Select all that apply
1. Handwashing at the beginning of shift 2. Sterile gloves whenever contamination possible 3. Be observant of signs of infection 4. Waterless hand cleaner should be used before glove removal 5. Perform sterile procedures carefully
Which statement is not true about end-of-life care?
a. The physician is the ultimate authority in the decision to use or not use life-sustaining medical treatment. b. The proxy appointed in a living will cannot speak for the testator in health care matters other than terminal illness. c. A patient with dementia can be capable of making personal wishes known about life-sustaining treatment. d. The American Nurses Association calls for nurses not to participate in assisted suicide.
The client is experiencing an increase in carbonic acid due to the failure of the lungs to adequately eliminate carbon dioxide, which results in:
a. metabolic acidosis c. respiratory acidosis b. metabolic alkalosis d. respiratory alkalosis