Kayla Marina, 68 years old, has an elevated blood pressure. What would be a goal for her care?
a. Resident's blood pressure will be less than 160/90 mm Hg in 1 week
b. Resident's blood pressure will be normal
c. Resident's blood pressure will not be elevated
d. Resident's blood pressure will be monitored t.i.d. for 1 week
A
Response A is a measurable, realistic, specific, time-related, and attainable goal. Responses B and C are stated as goals, but they are not specific. Response D is a nursing intervention.
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A) "How is it going?" B) "You say you aren't concerned, but you've asked me many questions on this same subject." C) "What do you mean when you say...?" D) "For now, I would like to concentrate on..."
The nurse admits a client in the early stage of labor and asks if the membranes have ruptured. The client states, "I don't know if my water broke or not." The nurse plans to call the physician, who will ask if membranes have ruptured
The nurse will: 1. Quote the mother's response and tell the physician that status of membranes is unknown. 2. Assume membranes are intact, or the client would know they ruptured. 3. Perform a pelvic examination to determine if membranes are intact. 4. Perform a Nitrazine test of vaginal secretions for presence of amniotic fluid.
The nurse understands that the most common use of neuromuscular blockade is to:
a. sedate clients with a head injury. b. treat the client with multiple sclerosis. c. facilitate intubation and mechanical ventilation. d. decrease spasticity and muscular rigidity.
The interpretation of your message is based on:Words used ____________________% tone of voice ____________________% gestures, facial expressions, and other body language ____________________%.
Fill in the blank(s) with the appropriate word(s).