During a neurologic assessment of a client, the nurse notes that the client's arms, wrists, and fingers have become flexed, and internal rotation and plantar flexion of the legs are evident. How does the nurse document these findings?
a. Decorticate posturing
b. Decerebrate posturing
c. Atypical hyperreflexia
d. Spinal cord degeneration
A
The client is demonstrating decorticate posturing, which is seen with interruption in the corticos-pinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The physician, the charge nurse, and other health care team members should be notified imme-diately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. The other two options are inaccurate.
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a. observing nurses caring for patients. b. screening patients who are admitted to the hospital. c. educating hospital personnel about aseptic practices. d. discharging infectious patients from the hospital.
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A. Inform the physician. B. Give her a pamphlet about escaping domestic violence. C. Notify the police. D. Refer her to a social worker and engage her in discussion about creating a safety plan.
A nurse is working with a community center that primarily serves a nearby Native American tribe. The nurse knows that many of the tribe members suffer from type 2 diabetes. Which of the following interventions is an example of a tertiary prevention?
A. Reviewing blood glucose testing techniques B. Routine blood glucose screening for everyone who comes into the clinic C. Actively encouraging diabetic patients to have foot, eye, and hemoglobin A1C screening tests every three months D. Publishing a guide about preventing diabetes and distributing it to people who are unaffected
An individual considering a self-help group says to a nurse, "I might go to the bereavement group meeting, but what if I'm required to make changes I don't like?" The nurse's most therapeutic response would be:
a. "Perhaps you're not quite ready to join a group. Give yourself a few more weeks.". b. "These are natural concerns. Trying something new activates all our insecurities.". c. "Most group members will feel just like you do. They will help you hold your own against aggressive group members.". d. "Self-help groups are designed so that each member has sole responsibility for making changes in his or her own life.".