During the acute CVA phase, there is a risk for falls related to paralysis. The intervention that best protects the patient from injury is:
1. keep the bed in a high position for ease of nursing care.
2. keep the side rails up, according to agency policy.
3. assess vision deficit related to ptosis.
4. monitor the condition every 2 hours.
2
Rails keep patients in bed. The bed should be low, monitoring the patient should be more frequent than every 2 hours, and visual assessment is not directly related to fall prevention.
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A patient with alcoholism will require which of the following vitamins due to inadequate dietary intake?
A) Niacin B) Vitamin A C) Vitamin C D) Thiamine
The nurse is calculating the body mass index (BMI) to assess a client's weight. Which is a limitation to using this tool?
1. There is lack of correlation of the values in the BMI table with those in height-weight tables. 2. Assumption that all individuals have equal body composition at each given weight. 3. BMI is difficult to accurately calculate. 4. The BMI's use to determine the risk for obesity is reduced in individuals who are on reduced calorie diets.
The technique of percussion requires practice and skill and is generally performed by nurse practitioners and physicians
Indicate whether the statement is true or false
A client with a family history of cancer asks the nurse what he can do to prevent developing the disease. Which of the following should the nurse respond to this client?
1. "Everyone develops cancer sometime in his life." 2. "There are lifestyle changes that you can make to avert the development of cancer." 3. "If you have cancer in your family, you will also develop the disease." 4. "Cancer cannot be prevented."