A client who has been exhibiting decorticate posturing after a stroke 2 days ago develops decerebrate posturing. The nurse should recognize that this change indicates the client's condition is:
a. worsening c. improving
b. unchanged d. an expected progres-sion of stroke
A
Any change from decorticate to decerebrate posturing indicates a worsening of the client's condition.
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The nurse is planning time to conduct an educational session with a client. Client education is important because it:
a. requires a physician's order before the nurse can implement a teaching plan. b. is a fiscally responsible intervention that encourages consumers to engage in healthy lifestyle practices. c. must be done in the outpatient setting because acute care nurses do not have time to teach. d. is the responsibility of the primary care physician.
Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy?
a. Bowel Obstruction related to recent abdominal surgery AMB: nausea, vomiting, and abdominal pain b. Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight c. Impaired Skin Integrity related to physical immobility AMB skin tear over sacral area d. Caregiver Role Strain related to alienation from family and friends AMB 24-hour care responsibilities
A client who is in her 14th week of pregnancy is in the clinic for a prenatal visit. Her mother also is present
The grandmother-to-be states that she is quite uncertain about how she can be a good grandmother to this baby because she works full-time, and her own grandmother was retired and was always available when needed by a grandchild. The best response to this concern would be: 1. "Don't worry. You'll be a wonderful grandmother. It will all work out fine." 2. "Grandmothers are supposed to be available. You should retire from your job." 3. "As long as there is another grandmother available, you don't have to worry." 4. "What are your thoughts on what your role as grandmother will include?"
When providing care to a client in the home setting, the nurse understands reimbursement sources such as Medicare will approve payment only on:
A) medications ordered by the physician. B) interventions provided by licensed nurses. C) interventions documented on the progress notes. D) interventions identified on the treatment plan.