A nurse explains to coworkers that care provided for a patient is based on the Nurse Practice Act (NPA), which covers the
1. Patient's Bill of Rights.
2. Rules and regulations that nurses must practice.
3. American Nurses Association's (ANA) guidelines.
4. Reasons that nurses may have action taken against their licenses.
ANS: 2
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Since returning from surgery the client has not voided for 8 hours; therefore, the nurse determines it is necessary to assess the client for bladder distention
The nurse would palpate for bladder distention with the client in which of the following positions? 1. Supine with only a small pillow under their head. 2. Prone position 3. Sitting in bed at a 45-degree angle 4. Lying in a left lateral position
The nurse is assessing CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). Which eye movements would the nurse document as nystagmus? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. The patient's eyes move together through the six cardinal positions of gaze. 2. The patient's eyes "jerk" horizontally instead of moving smoothly. 3. The patient's eyes move in a rotary fashion when attempting to follow the examiner's finger. 4. The patient's eyes cross when following the examiner's finger. 5. The patient's eyelids droop when the eye is moved to the left.
A patient diagnosed with depression confidently tells the nurse, "I've been supplementing my paroxetine (Paxil) with St. John's wort. It has helped a great deal." What is the nurse's priority action?
a. Assess changes in the patient's level of depression. b. Remind the patient to use a secondary form of birth control. c. Educate the patient about the risks of selective serotonin syndrome. d. Suggest adding valerian to the treatment regimen to further improve results.
A 15-year-old girl is brought to the clinic by her mother because the girl has been experiencing irregular and sporadic menstrual periods and excessive body hair growth. Polycystic ovary syndrome is suspected. Which additional assessment finding would help to support this suspicion?
What will be an ideal response?