J.R. is transported to radiology for a Ct scan; he is found to have a large epidural hematoma on the right
with a hemispheric shift to the left. He is taken straight to the operating room for evacuation of the hema
toma.
While he is in surgery, J.R.'s family arrives with their faith healer. they ask that their faith healer
anoint J.R. and pray over him.
How should you respond?
• Explain you are very sorry they missed him, but he had to be taken immediately to surgery. Tell the
family that as soon as he is out of surgery and in the neurologic intensive care unit and stable, a
nurse will notify them that they or their faith healer can visit him.
• Instruct the family where they can wait until the surgery is done so they can talk with the
physician.
• Call the operating room and notify the physician that the family has arrived and where they will be
waiting to talk to the physician postoperatively.
• Offer to make them comfortable and ask whether there is anything they need.
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The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. Which is appropriate for the nurse to use when documenting this finding in the medical record?
1. Hyperreflexia. 2. Babinski response. 3. Brudzinski sign. 4. Nuchal rigidity.
Which factors could influence oral temperature measurement? Select all that apply
1. Smoking 2. Eating or drinking 3. Exercise 4. Perfusion 5. Time of day
The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse
a. Completes a comprehensive database. b. Identifies pertinent nursing diagnoses. c. Intervenes based on patient goals and priorities of care. d. Determines whether outcomes have been achieved.
Upon what variable are Duvall's developmental stages based?
a. Age of the oldest child b. Age of the parent or parents c. Family function d. Family structure