A patient was admitted after falling from the roof of a one-story building. Assessment reveals presence of a patellar reflex, but loss of sensation in part of both feet. The nurse would plan for which level of bowel and bladder function?
1. Bladder function only
2. Bowel function only
3. Intact bladder and bowel function
4. Loss of both bladder and bowel function
4
Rationale 1: This assessment indicates a lesion around L3 or L4. Bladder continence would be lost.
Rationale 2: This assessment indicates a lesion around L3 or L4. Bowel continence would be lost.
Rationale 3: This assessment indicates a lesion around L3 or L4. Bladder and bowel continence would be lost.
Rationale 4: This assessment indicates a lesion around L3 or L4. Bladder and bowel continence would be lost.
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The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if the client was exposed to tuberculosis?
A) The client will have a productive cough. B) The injection area swells if the client has developed antibodies against the antigen. C) The injection area will become painful with induration if the client has antibodies against the antigen. D) The injection area will break out in a fine macular rash.
The nurse in the health center on a college campus is talking to freshman students about the consequences of drinking alcohol. The nurse defines a standard drink as:
A) 12 ounces of regular beer. B) 6 ounces of malt liquor. C) 4 ounces of table wine. D) 3 ounce shot of whiskey.
How can the nursing staff encourage sleep in long-term care facility residents? (Select all that apply.)
a. Using the minimum light necessary when making rounds b. Making necessary sleep interruptions at the same time every night c. Keeping conversational noise at the nursing station to a minimum d. Answering call lights promptly e. Providing heavy blankets for warmth
The family of a frail, elderly client is seeking your professional guidance for the difficulty they are having coping with caring for this family member. They are experiencing which of the following?
1. ineffective coping 2. dysfunctional coping 3. effective coping 4. poor coping