The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.)
a. Use of a heparin flush solution
b. Manually flushing the device "prn"
c. Recording ICP as a "mean" value
d. Use of a pressurized flush system
e. Zero referencing the transducer system
C, E
Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Munro. Manually flushing the device may result in an increase in ICP.
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The nurse conducts a focused neurological assessment of the client with a seizure disorder by doing which of the following? .Select all that apply. Standard Text: Select all that apply
1. Assessing pupils for accommodation and response to light 2. Assessing general mental status 3. Checking grip strength bilaterally 4. Assessing pain status 5. Measuring visual acuity
The nurse is caring for several clients, and has an unlicensed assistive personnel (UAP) and LPN/LVN assisting. Which client would the nurse delegate to the LPN/LVN as opposed to the UAP?
1. Assisting the health care provider with performance of a lumbar puncture 2. Collecting and testing a routine urine specimen for sugar, protein, and specific gravity 3. Testing stool for the presence of occult blood 4. Collecting a sterile urine specimen by straight-catheterizing the client
An interview with a depressed client reveals to the nurse that psychodynamic factors may underlie the client's depression. Psychodynamic theory attributes the development of mood disorders to which of the following?
A) Unexpressed and unconscious anger B) Repressed sexuality C) Current situational difficulties D) Loss of cultural identity
An adult child of an older adult confides in the nurse that the patient has lost most of her friends because of her negative behavior. What action by the nurse is best?
a. Ask when the patient had her last physical exam. b. Encourage the patient to be more positive. c. Ask if the patient is aware of the problem. d. Suggest the patient take antidepressants.