The nurse assists the patient who had a recent cerebral vascular accident (CVA or stroke) with drinking water, and the patient begins to choke. Which intervention is the best choice to meet the patient's priority need?
a. Provide oxygen.
b. Suction the patient.
c. Call for assistance.
d. Recline the patient.
B
The patient's priority needs, in order, are airway, breathing, and circulation (ABCs), so the nurse's priority action is to maintain the airway. To accomplish this, the nurse suctions the patient to prevent an airway obstruction. After the airway is clear, the nurse can provide supplemental oxygen as prescribed if the patient continues to have difficulty or has oxygen desaturation from choking. If the patient continues to have difficulty, the nurse should call for help to obtain emergency equipment. The nurse can place the patient in the recovery position after choking if the patient loses consciousness, continues to choke, or starts to retch or vomit. Reclining the pa-tient is contraindicated because it increases the risk of aspiration.
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a. discusses with the patient changes that happened during the relationship and evaluates outcomes. b. gives the patient the nurse's cell phone number and permission to call after discharge. c. avoids upsetting the patient by shifting focus to other patients before the patient's discharge. d. offers to meet the patient for conversation after discharge.
Discuss the three neuromuscular disorders involving the nervous system, which directly or indirectly affect the muscles also
a. What do they have in common? b. What is the nursing process for these disorders?
Which nursing theorist is best known for her emphasis on interacting systems, including nurse and patient in goal setting and goal attainment?
a. Watson b. Roy c. King d. Orem
The nurse is assisting as a neurosurgeon examines a patient who has a positive Babinski reflex. What assessment finding should the nurse expect to observe?
a. The leg flexes when the patellar tendon is struck. b. The leg extends when the patellar tendon is struck. c. The big toe extends when the sole of the foot is stroked. d. Toes curl downward when the sole of the foot is stroked.