A patient in balanced suspension traction can have the head of the bed raised only 30 degrees. To promote normal elimination, patients need to assume a sitting position to:
A. stimulate the peristaltic movement.
B. contract the thigh muscles used to defecate.
C. strengthen the internal and external sphincters.
D. exert intra-abdominal pressure, which aids in defecation.
D
Physiological factors critical to bowel function and defecation include normal GI tract function, sensory awareness of rectal distention and rectal contents, voluntary sphincter control, and ade-quate rectal capacity and compliance. Contraction of abdominal muscles at times aids in defeca-tion. When stool reaches the rectum, the internal sphincter relaxes.
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The nurse provides teaching about digoxin to the 62-year-old patient. The nurse evaluates patient understanding and determines further teaching is needed when the patient says she will do what?
A) "Take the medication daily in the morning." B) "Take her pulse before taking her dose." C) "Weigh herself daily at the same time." D) "Take the medication with a meal."
The nurse at a student health center at a university is assessing a first-year student. The student is from out of state. The student discloses that he has never felt comfortable “as a guy” and feels terribly alone. What will the nurse include as a priority during the assessment?
a. Nutrition assessment b. Suicide assessment c. Mental status examination d. Body mass index
A nurse who is auscultating a client's heart hears a harsh sound, a raspy machine-like blowing sound after S1 and before S2. The nurse documents this finding as:
a. An opening snap. b. A diastolic murmur. c. A systolic murmur. d. A pericardial friction rub.
The patient is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape in which manner?
a. At a 45-degree angle to the skin surface while pulling away from the dressing b. At a right angle to the skin surface while pulling toward the dressing c. At a right angle to the skin surface while pulling away from the dressing d. Parallel to the skin surface while pulling toward the dressing