The nurse gives the patient the following instructions: "Focus on my pencil and follow it as I move it away from you and then back toward you." The nurse is assessing the
1. Anisocoria of the patient's pupils.
2. Patient's accommodation response.
3. Patient's consensual reflex.
4. Direct pupil response of the patient.
ANS: 2
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A female client on the mental health unit experiences periods of psychosis at intervals. She often asks what day she came to the facility and what day it is now, and she seems never to be aware of the time
Which nursing intervention would help this client the most? a. Remind her of the time of day every time she asks. b. Assist her to keep a written schedule, including her day of admission, on a calendar posted in her room and a clock beside the calendar. c. Tell her it doesn't really matter what day she came to the facility; what matters is what day and time it is now. d. Instruct the staff to not answer her repetitive questions because she has been told numerous times her day of admission, and there is a clock on the wall.
A group of nurses are discussing the benefits of the blood-brain barrier, which statement made by one of the nurses regarding the blood-brain barrier demonstrates a need for further teaching?
a. It can protect the brain from injury by potentially toxic substances. b. It can be a significant obstacle to entry of therapeutic agents. c. It is not fully developed at birth. d. Infants are not as sensitive to central nervous system drugs as older children and adults.
A father expresses to the nurse that he does not want to be present for the birth of his child. What action by the nurse is most appropriate?
a. Tell him most fathers are present for the birth and are pleased with the experience. b. Ask him why he does not want to be there for his wife and child. c. Tell him it is his choice. d. Explore his concerns and support his decision.
The purpose of the fetal evaluation technologies include which of the following? (Select all that apply.)
a. evaluation of nursing interventions d. alter decelerations b. treat congenital ano-malies e. diagnostic testing c. screening procedures f. reassurance proce-dures