The nurse assessing a client for acute confusion recalls that the client:
1. will be disoriented only as to place.
2. will be disoriented only as to time.
3. will only rarely forget his or her own identity.
4. is never disoriented to persons.
ANS: 3
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True leg length should be measured from the:
A) Anterior superior iliac crest to the medial malleolus. B) Sternal notch to the medial malleolus. C) Umbilicus to the medial malleolus. D) Umbilicus to the tibia.
When assessing the relative advantages and disadvantages of internal and external electronic fetal monitoring, nurses should be aware that both:
1. can be used when membranes are intact. 2. measure the frequency, duration, and intensity of UCs. 3. may need to rely on the woman to indicate when UA is occurring. 4. can be used during the antepartum and intrapartum periods.
A nurse working at a nursing home is administering medications. The nurse misreads the medication orders and administers a medication via the intravenous line, rather than via an intramuscular injection
The client sustains permanent injuries and eventually dies. This nurse charged with: a. misfeasance. b. nonfeasance. c. malfeasance. d. malpractice.
When evaluating a health care team member's ability to digitally remove feces, the nurse determined that further teaching is required in which of the following situations?
a. Staff member provides perianal skin care. b. Staff member continues the procedure if bleeding starts. c. Staff member follows the procedure by offering the patient the bedpan. d. Staff member discontinues the procedure in the presence of bradycardia.