You are getting ready to transfer your patient from the bed to a chair for the first time after surgery. Which of the following are important to assess? (Select all that apply.)
a. Sensory status
b. Temperature
c. Upper arm strength
d. Postural hypotension
e. Cognitive status
f. Pain level
A, C, D, E, F
To provide for a safe transfer it is important to assess sensory status, including central and peri-pheral vision, adequacy of hearing, and presence of peripheral sensation loss. This will impact the ability of the patient to contribute to a safe transfer. Patients with visual and hearing losses need transfer techniques adapted to deficits. Immobile patients can have decreased muscle strength, tone, and mass, which affects the ability to bear weight or raise the body. Assess presence of weakness, dizziness, or orthostatic (postural) hypotension. Rationale: Determines patient's risk of fainting or falling during transfer. The move from a supine to a vertical position redistributes about 500 mL of blood; immobile patients may have decreased ability for the autonomic nervous system to equalize blood supply, resulting in orthostatic hypotension. Assess the patient's cognitive status, including ability to follow verbal instructions. Assess the patient for pain (e.g., joint discomfort, muscle spasm) and measure level of pain using a scale from 0 to 10 . Offer prescribed analgesic 30 minutes before transfer. Temperature does not affect the transfer process.
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1. "Since nurses are the only ones using this system, I won't have to wait to document anymore." 2. "I'm glad that it will take less time for us to document." 3. "I hope we don't have to keep changing passwords." 4. "They say that our patient care will improve while we are using this system."
The reduction in the size of the uterus immediately after birth is referred to as:
a. Exfoliation b. Involution c. Puerperium d. Regeneration
A client is ordered to receive carisoprodol (Soma) for muscle relaxation. The client takes the medication for 3 weeks and then abruptly stops. The client is at increased risk for:
a. excessive muscle relaxation. b. decreased range of motion. c. increased inflammation. d. rebound muscle spasms.