It is necessary to measure a patient's height, but the patient's legs are suspended in traction. Which nursing action is indicated?
1. Measure from the patient's head to the iliac crest and use a standard table to estimate height.
2. Remove the traction weights long enough to quickly measure length of one leg.
3. Measure the patient's arm span.
4. Estimate the patient's height from his stated weight.
Answer: 3
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A patient who is concerned that she may have serious heart disease seeks help at the mental health center after her internist examined her and told her that she has no physical illness
She wants staff to tell her internist it's not all in her head. The patient reports she has had tightness in her chest and the sensation of her heart missing a beat. Her concern over her symptoms has caused her to miss much time from work over the past 2 years, and her social life has been severely restricted because she believes she must rest each evening. This presentation most suggests: a. somatization disorder. b. pain disorder. c. body dysmorphic disorder. d. hypochondriasis.
The client who has had a total hip replacement asks when she will be able to use a regu-lar-height toilet seat. What is the nurse's best response?
A. "As soon as you are able to walk without a limp." B. "As soon as the staples have been removed from the incision." C. "When the pain is gone and you are no longer taking warfarin (Coumadin)." D. "When you can hold your leg straight off the bed 6 inches for 5 full minutes."
Which scenario should the nurse follow up on as a potential indication of intimate partner violence?
A) The partner of a pregnant woman attends each of her appointments. The partner is friendly and outgoing. Each time the nurse asks the patient a question, the partner answers. While the partner speaks, the patient looks at her lap. B) The partner of a pregnant woman attends each of her appointments. The partner is friendly and outgoing. Each time the nurse asks the patient a question the partner tries to answer. When the partner speaks, the patient interrupts and answers the question herself. The partner listens to the answer. C) The partner of a pregnant woman attends an ultrasound appointment. The partner is friendly and outgoing. When the technician reveals the patient's belly to apply the electrodes, the partner comments that the patient is really fat. The patient pulls at the partner's shirt and says the partner is fat too. They both laugh. D) The partner of a pregnant woman attends an ultrasound appointment. The partner is friendly and outgoing. The nurse notices bruises on the patient's upper arms and says they look sore. The patient says she's getting so big she keeps bumping into things. She maintains good eye contact with the nurse as she explains.
To move an immobile patient up in bed,
A) ask another member of the nursing staff to work with you. B) you should always use a mechanical patient-lifting device. C) you should slide and lift the patient. D) you should move the patient as quickly as possible.