Which nurse is performing the technique of light palpation appropriately?
a. Nurse A applies the bimanual technique to determine size and location of the patient's heart.
b. Nurse B uses the fingertips to feel for temperature differences on the patient's legs.
c. Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations.
d. Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations.
ANS: C
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A child with rheumatic fever begins involuntary, purposeless movements of her limbs. What does the nurse recognize that this indicates?
a. Seizure activity b. Hypoxia c. Sydenham's chorea d. Decreasing level of consciousness
A nurse is teaching a group of pregnant clients regarding seizures associated with eclampsia. The nurse will include which statement?
A) "The tonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles." B) "The clonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity." C) "Seizures are rare in eclampsia, but they occur sometimes." D) "Seizures do not occur in preeclampsia."
Which organization developed standards of nursing practice that define holistic nursing practice as a specialty?
1. AHNA 2. ANA 3. NCCAM 4. ANCC
The proper procedure to be used when removing a dressing that is sticking to a wound is by
A. placing a heating pad on the wound to loosen the scab. B. softening the dressing with normal saline. C. gently pulling the dressing off from front to back. D. spraying the dressing with an anesthetic to reduce patient discomfort.