A client has been scheduled for an above-the-knee amputation. The RN performs a nursing assessment of the client's impaired extremity. This will include assessing the color of the skin, the temperature, pulse, and limb movement
What also would be included in this specific assessment? a. An assessment of the client's upper extremity
b. The unaffected lower extremity
c. The client's blood pressure
d. The client's mobility
B
Objective assessment data include the color and temperature of the skin, pulse, and responses to limb movement. The unaffected extremity also is assessed for function and circulation and compared to the affected extremity.
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The nurse is educating the patient on the use of relaxing therapy. Which statement by the patient indicates a need for further education?
a. "I should relax my muscles from head to toe." b. "I visual the relaxed muscle." c. "I should do this three times a week." d. "I focus on muscles that are tense."
Which assessment data suggests a person who appears to have dementia instead has depression and pseudodementia?
a. Demonstrates impaired judgment b. Demonstrates impaired concentration c. Has a history of significant losses or crises d. Cognitive changes preceded mood changes
A nurse is caring for a patient with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy (UGF). How should the nurse in the radiology department prepare this patient?
A) Insert a nasogastric tube. B) Administer a micro Fleet enema at least 3 hours before the procedure. C) Have the patient lie in a supine position for the procedure. D) Apply local anesthetic to the back of the patient's throat.
You are the circulating nurse in an outpatient surgery center. Your patient is scheduled to receive moderate sedation. You know that a patient receiving this form of anesthesia should:
A) Never be left unattended by the nurse B) Receive an antiemetic C) Remember most of the procedure D) Be able to maintain his or her own airway