Which outcome should the nurse use for evaluation of the efficacy of interventions designed for this nursing diagnosis?
a. the client's family inspects the skin for reddened areas daily
b. the client exhibits no reddened areas or breaks in the skin
c. the nursing staff rotates the client's kinetic bed per unit protocol
d. the physical therapist performs passive ROM exercises
Answer: b. the client exhibits no reddened areas or breaks in the skin
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The emergency department nurse manager is explaining concepts of emergency and disaster preparedness to a group of students. Which statement by the nurse manager is most accurate?
a. "An internal disaster is something that occurs inside the health care facility." b. "An external disaster occurs when some-one not employed here disrupts our opera-tions." c. "A multi-casualty event involves disasters at several different locations." d. "The Joint Commission requires that we participate in a disaster drill once a year."
The 75-year-old client tells his nurse that this is the first time he will have had his intraocular pressure measured and that he only came because his daughter insisted
He also says that he is afraid the test will hurt and that he might find out he has glaucoma and will go blind. What is the nurse's best response? A. "The test is painless because you will receive a sedative. If you have glaucoma, the correct glasses or contact lenses can prevent blindness." B. "The test is quick and painless because a local anesthetic is used. Early detection of glaucoma allows medications and other procedures to prevent blindness." C. "The test does cause a little pain, but it is over very quickly. This test, however, does not determine whether or not you have glaucoma or are at risk for glauco-ma." D. "The test causes some pain and tearing, but you can have your daughter present to hold your hand. It is unlikely that you have glaucoma because no one in your family has it."
Which of the following would be considered a sentinel event?
a. Patient who has developed a fatal mediastinal infection 7 days after cardiac sur-gery b. Patient who experiences a CVA during a cardiac catheterization c. Patient who receives a double dose of a medication in error d. Wrong patient scheduled for a chest radiograph
The patient had a stroke and is currently immobile. The nurse realizes that increasing mobility is critical because immobility can result in alterations in which of the following? (Select all that apply.)
a. Cardiovascular function b. Pulmonary function c. Skin integrity d. Elimination