What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest?
1. Assess motor and sensory function every shift.
2. Have the patient hold onto the halo struts during turns and repositioning.
3. Keep the pins and traction bars slightly loose to prevent pressure ulcers.
4. Tape a halo vest wrench to the front of the vest.
5. Use a moist cloth to clean the skin under the vest.
4, 5
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Which finding is considered normal and expected when the nurse is performing a physical examination on a pregnant woman?
a. Palpable, full thyroid b. Edema in one lower leg c. Significant diffuse enlargement of the thyroid d. Pale mucous membranes of the mouth
The nurse is preparing teaching material for a group of young adults about measures that can help prevent peripheral vascular disease (PVD). What should the nurse include in this teaching?
1. Eating low-sodium diets. 2. Decreasing fat and cholesterol in the diet at age 50. 3. Avoiding smoking after age 40. 4. Maintaining a healthy weight.
A patient was admitted to the emergency department for treatment of a severe infection. Which traditional assessment would raise the nurse's concern that this patient may be developing shock?
1. Hot, dry skin 2. Respiratory rate 11 3. Pulse rate 118 and weak 4. Anxiety
he nurse is monitoring a patient for progression through the grades of hepatic encephalopathy (HE). This morning the patient is exhibiting a positive Babinski reflex. The nurse would conduct additional assessment about which HE grade?
1. I 2. II 3. III 4. IV