After assessing a client's plantar reflex, the nurse documents that the finding was normal. Which of the following did the nurse assess in this client?
1. Extension of the toes
2. Flexion of the toes
3. No movement of the toes
4. Spasming of the toes
2
The normal response is flexion of the toes. Any other response could signify neural impairment.
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A nurse is obtaining a health history on a new patient with oral cancer. The patient had surgery earlier today. What is the priority postoperative assessment for the nurse caring for this patient?
A) Assess ability to clear oral secretions B) Assess ability to pucker lips C) Assess for a patent airway D) Assess for ability to communicate
The nurse is teaching a client with a spinal cord tumor about the treatment plan. Which statements indicate that the client correctly understands the teaching? (Select all that apply.)
a. "Because my symptoms occurred so quickly, I am likely to be cured quickly by surgery." b. "Radiation therapy can shrink the tumor but radiation can cause more problems, too." c. "I am glad you are here to turn me. Lying in one position for a long time makes my pain worse, even if turning is uncomforta-ble." d. "I have put my affairs in order and pur-chased a burial plot because this type of cancer is almost always fatal." e. "My family is making some changes at home for me, including moving my bed-room downstairs."
According to the complexity theory, which of the following should be the focus of measurement?
a. Cost per hospital day b. Bed utilization c. Infection rates d. Staff morale and budgets
A nurse recognizes that the newly admitted client may be at risk for falling because of a history of:
A. Allergies B. Urinary retention C. Sedative/analgesic use D. Alternative therapy use