A nurse notices a client sitting at the edge of the chair, tapping her fingers, fidgeting, and blinking her eyes frequently
In planning this client's care, the nurse should take into account that this client is most likely displaying nonverbal cues of: 1. Shyness.
2. Anxiety.
3. Anger.
4. Interest.
2
Rationale 1: A person experiencing shyness might hide her hands and have minimal eye contact with the other person.
Rationale 2: All of these nonverbal behaviors typically are expressed in a person who is experiencing feelings of anxiety.
Rationale 3: A person who is experiencing anger might appear rigid or tense, clench her fist, or tap her fingers.
Rationale 4: Someone who is interested typically looks the other person in the face, leans forward, has frequent eye contact, and/or touches the arm or hand of the other person.
Global Rationale:
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A nurse would like to advocate for a modification of the state's nursing practice act and believes the best strategy is to contact the persons with authority to write and change this statutory law. Whom should the nurse contact?
1. State board of nursing 2. State governor 3. State legislature 4. State nursing association
Which of the following is the best example of a monitoring system?
1. Manual blood pressure of 132/82 is entered into the vital sign section of the graphic sheet. 2. The automatic blood pressure machine takes one reading of 164/104 and is turned off. 3. Blood glucose readings of 162 for 7:30 a.m. and 198 for 11:30 a.m. are obtained and entered into the computer system. 4. A temperature probe is connected to the pulmonary artery catheter to continuously monitor core temperature.
The nursing student demonstrates an understanding of the Health Insurance Portability and Accountability Act (HIPAA) by:
a. using the patient's full name only on clin-ical assignments submitted to the instruc-tor. b. using the facility printer to copy lab re-ports on an assigned patient. c. shredding any documents that the student has been using that contain identifying patient information before leaving the clinical facility. d. asking the patient for permission to copy lab and diagnostic reports for educational purposes.
The nurse is caring for a child with a subdural hematoma. The nurse should assess for what signs that can indicate brainstem compression? (Select all that apply.)
a. Coma b. Lethargy c. Hemiplegia d. Hemiparesis e. Unequal pupils