When a nurse is assessing a client's mental status, which observation is pertinent to this exam?
a. assessment of pupil size, equality, roundness, and reaction to light
b. evaluation of both long-term and short-term memory, and memory recall
c. observation of behavior, posture, gestures, and facial expression as compared to expected behaviors of clients of same age, health status, educational level, and social position
d. observation of client's affect as appropriate for the situation
C
Assessment of mental status requires observation of the client's appearance, behavior, posture, mood, gestures, movements, and facial expressions. The nurse compares these behaviors to expected behaviors based on the client's age, health status, educational level, and social position.
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The nurse recognizes that working with children with a different cultural perspective may be especially difficult because:
a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents' perceptions of the illness. d. Parents are often the decision makers, and they have no knowledge of their children's spiritual needs.
Your patient tells you that he has just been told that his computed tomography results were abnormal. You can expect that his sympathetic nervous system has stimulated his adrenal gland to release what?
A) Endorphins B) Dopamine C) Epinephrine D) Testosterone
What instruction should a nurse provide to a patient scheduled for a postvoid residual (PVR) test?
a. Call the nurse immediately after voiding. b. After voiding, wait 10 minutes and void again. c. Void into a flow meter. d. Avoid fluid intake for 8 hours before the test.
The nurse is participating in the use of Ranson's criteria to assess a patient with pancreatitis. Which statement reflects a disadvantage of using these criteria?
1. It takes 48 hours for complete assessment. 2. Ranson's criteria are not valid for patients over 55. 3. This scoring system is not useful for persons with renal disease. 4. Invasive testing is necessary as part of Ranson's criteria.