Which should the nurse delegate to the nursing assistant?
1. Measure bilateral plantar and patellar reflexes.
2. Assess the function of cranial nerves III, IV, and V.
3. Observe and report on client's level of consciousness.
4. Compare symmetry of motor responses to painful stimuli.
3
3. The nurse directs the nursing assistant to observe and report on the client's level of consciousness and requests specific information about the client's level of con-sciousness so the nurse can draw a conclusion from the data.
1. Measuring deep tendon reflexes is an assessment skill performed by the nurse.
2 and 4. The nurse performs all assessments, including those of the cranial nerves and responses to painful stimuli, as part of the nursing process.
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To assess a rectal temperature accurately in an adult, the nurse would:
a. Use a lubricated blunt tip thermometer. b. Insert the thermometer 2 to 3 inches into the rectum. c. Leave the thermometer in place up to 8 minutes if the patient is febrile. d. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
The student nurse asks why he needs to assess a patient's spirituality when he can call the chaplain. What response by the nurse is best?
a. "This way you learn what is involved in a spiritual assessment." b. "Students need to perform all aspects of patient care." c. "Regulatory organizations list this as a required BSN competence." d. "All patients should have a spirituality assessment."
Which of the following accurately describes the relationship among complementary, alternative, and conventional medicine?
a. Alternative modalities are those that are used instead of conventional medicine. b. Complementary modalities are used only when conventional medicine is not used. c. Conventional medicine incorporates complementary modalities solely in psychiatry. d. Conventional, complementary, and alternative medicine are one and the same.
A client notices that the health care provider writes "positive Chadwick's sign" on her chart. She asks the nurse what this means. Which is the nurse's best response?
a. "It means the cervix is softening." b. "That refers to a positive sign of pregnancy." c. "It refers to the bluish color of the cervix in pregnancy." d. "The doctor was able to flex the uterus against the cervix."