An 83-year-old man becomes lost while driving. He pulls into a driveway to turn around and cannot figure out how to put his car in reverse, so he drives into the yard, makes a circle, and drives back out of the driveway
The police who observe this action pull him over, quickly determine that he is cognitively impaired, and take him to the emergency room. Which evaluations would the emergency room nurse expect to see ordered? Select all that apply. a. Folate and b12 levels
b. Electrolytes and serum creatinine
c. Hearing and vision screening
d. Psychological testing
e. Mental status examination
f. Brain imaging
A, B, C, E, F
Many medical and psychiatric disorders can present as dementia and must be ruled out before a diagnosis of dementia is reached. Evaluation must address all issues that potentially affect mental status, including nutritional elements necessary for brain function, metabolic factors, sensory changes, and brain imaging to detect structural changes such as atrophy. A complete mental status examination identifies nervous system deficits such as impaired memory or executive function. The only examination here that is not typically performed in the emergency room is psychological testing, which is a lengthy process that requires a psychologist and thus is rarely feasible in the emergency room.
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Which of the following statements made by a parent indicates a need for the nurse to teach safety and accident prevention?
a. "I make sure I always raise the side of the crib when I put my baby to sleep, even though newborns don't move around as much as older infants." b. "I've been reading about what new things my baby will be learning to do in the next month or two, so I'll know what to expect." c. "I'm going to buy a backpack for my 2-week-old baby so I can carry her in it whenever she gets fussy." d. "I always take the phone off the hook when I give my baby a bath so I won't be disturbed."
At her 36 weeks' gestation prenatal visit, a client complains of backaches and an "unstable" sensation in the pelvis. The nurse should explain to the client that these are normal discomforts of pregnancy primarily due to:
a. depletion of calcium from maternal bones to supply fetal skeletal development b. engagement of the fetus in the pelvis c. softening of the pelvic cartilages as a result of hormonal influence d. posture changes as a result of the growing uterus
A nurse is providing care for a female patient who remains unconscious following an ischemic stroke that she suffered 4 days ago
When providing eye care to remove mucus and debris from the eye, the nurse should use which of the following techniques? A) Use a cotton swab to gently clean from the outer (lateral) canthus to the inner (medial) canthus of each eye. B) Use a gentle up-and-down motion to cleanse each eye with a cotton ball, using a different cotton ball for each eye. C) Use a cotton ball or small gauze to wipe from the outer canthus to the inner canthus of each eye. D) Using one cotton ball for each eye, wipe from the inner to outer canthus of each eye.
If the client cannot void within 4 hours after surgery, the nurse notifies the physician unless catheterization orders are in place
Indicate whether the statement is true or false