The nurse recognizes that the earliest and most sensitive indication of altered cerebral function is:
a. Unequal pupils.
b. Loss of reflexes.
c. Paralysis.
d. Change in level of consciousness.
ANS: D
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What nursing action will significantly decrease the risk of serious complications for a child in Bryant's traction?
a. Neurovascular checks are done frequently. b. Bandages are wrapped tightly. c. The child is restrained from rolling over. d. The child's buttocks are resting on the bed.
The patient says, "I just don't think I can keep going on. I just want it all to end." The nurse assesses that this patient has suicidal ideation. Your best response is:
1. "Do you have any thoughts of harming yourself?" 2. "Have you felt like this before?" 3. "You are just depressed. Once you feel better, you won't think that way." 4. "We will keep you safe here."
Which of the following is the best developed task statement?
a. The client will walk up and down the hall. b. The client will monitor his blood sugar and take his insulin injection correctly. c. The client will walk up and down the hall three times a day by 24 hours from this day. d. The client will be able to regulate his blood sugar.
The nurse is implementing a plan of care for a patient. After providing care, what should the nurse do as the final step in the process?
A. Measure vital signs B. Document C. Reassess the patient D. Provide report to the charge nurse