The nurse is assessing the muscle stretch reflexes on a client who has repeatedly demonstrated 3+ responses. The nurse recognizes the implication of this data to mean that:
1. While brisk, it may be normal for this client.
2. This is a below-normal response.
3. There is indication of central nervous system dysfunction.
4. This is generally considered a normal response.
While brisk, it may be normal for this client.
Rationale: A 3+ response or grade is considered brisk but may be normal for some individuals; normal response is generally graded as a 2+; 1+ is a diminished response while a 4+ is indicative of CNS dysfunction.
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A client is returning to the nursing unit after an intermaxillary wiring to treat a facial fracture. What equipment is vital for the nurse to have at the bedside? (Select all that apply)
a. Scale b. Suction set-up c. Thermometer d. Wire cutters
After a mastoidectomy, the most important complication for the nurse to assess for is:
1. vomiting. 2. headache. 3. fever. 4. stiff neck.
The nurse is preparing to discharge a client with a urinary tract infection (UTI) from the urgent care center. The nurse tells the client to call the health care provider is the current fever does not diminish below ____ degrees Celsius within 3 days
Standard Text: Record your answer rounding to one decimal place. Fill in the blank with the appropriate word.
When preparing a patient for an intravenous pyelogram (IVP), the nurse reviews diagnostic data. Which finding should the nurse report to the healthcare provider before sending the patient for the test?
A. Residual urine of 80 mL B. Urine culture <10,000 organisms/mL C. Blood urea nitrogen (BUN) 55 mg/dL D. Serum creatinine 1.3 mg/dL