The fiercely independent 90-year-old woman who is recovering from a stroke frequently ambulates without the use of her walker because she says it is ugly and cumbersome. The nurse's most effective intervention would be to:
a. allow her to ambulate independently.
b. place a gait belt around her and ambulate when she does.
c. bring her walker to her and remind her that the walker is for her safety.
d. instruct her to use a wheelchair for mobility.
ANS: C
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A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of which of the following?
A) Tonus B) Flaccidity C) Atony D) Spasticity
What steps should a nurse take when administering an intravenous (IV) push drug through a peripheral intermittent device? (Separate the letters with a comma and space: A, B, C, D.)
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The nurse is caring for a pregnant 16-year-old who says, "I don't want my mother to know I'm pregnant. Please don't tell her." The nurse's best response would be:
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Mrs. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and doesn't say anything in response to your question. This is an example of which type of challenging patient?
A) Talkative patient B) Angry patient C) Silent patient D) Hearing-impaired patient