When planning the care for a client who has a spinal cord injury, the nurse should perform which action first?
1. Testing for motor strength
2. Listening for bowel sounds
3. Palpating the client's bladder for fullness
4. Monitoring the client's blood pressure
Answer: 4
1. Testing for motor strength is not a priority.
2. Listening for bowel sounds should be done after assessing blood pressure.
3. Palpating the bladder for fullness should be done after assessing blood pressure.
4. An exaggerated sympathetic response leads to autonomic dysreflexia, which can lead to a hypertensive crisis. A full bladder or distended bowel can trigger the response.
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An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a "steering wheel mark" across the client's chest. Which action should the nurse take?
a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.
The parents of a newborn male ask the nurse if they should circumcise their son. The best response by the nurse is: "Circumcision:
1. "Should be undertaken to prevent problems in the future." 2. "Might decrease the risk of developing a urinary tract infection." 3. "Can sometimes cause complications. What questions do you have?" 4. "Is painful, and should be avoided unless you are Jewish."
The home health assistant contributes to the ____________________ component of the nursing process by being honest in appraising whether the client still needs services and by being accurate and concise in reporting.
Fill in the blank(s) with the appropriate word(s).
A patient with Alzheimer disease is no longer able to make or plan meals and is having difficulty managing her personal finances. For which stage of Alzheimer disease should the nurse plan care for this patient?
1. Preclinical 2. Mild cognitive impairment 3. Dementia 4. Asymptomatic