A patient, admitted to the intensive care unit after cardiac surgery, needs to be placed on a ventilator to maintain respirations. Which of the following should the nurse add to the routine assessment of this patient?
1. musculoskeletal functioning
2. mentation
3. risk for falls
4. placement of wrist restraints
2
Rationale: Since abnormalities in mentation occur in 80% of ventilator-dependent patients, the nurse needs to routinely assess the patient's mentation status. The other choices may or may not be necessary depending upon the patient's status and needs.
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