Tissue ischemia and nerve damage are serious complications that may result from immobilization in a cast or from traction. The five Ps of vascular impairment can be used as a guide when assessing for neurovascular problems. List the five Ps
What will be an ideal response?
pain, pallor, pulselessness, paresthesia, paralysis
Prompt referral to a physician and intervention is crucial if neurovascular impairment is to
be prevented.
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Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?
a. S3 when sitting up b. Persistent tachycardia above 150 beats per minute c. Murmur at the second left intercostal space when supine d. Palpable apical impulse in the fifth left intercostal space lateral to midclavicular line
The patient with nephrosis complains about the need for bed rest. How would the nurse explain the benefit of bed rest?
a. The recumbent position may initiate diuresis. b. It preserves the skin integrity. c. It lowers the level of albuminuria. d. It saves stress on joints.
The nurse takes special care to be gentle in caring for patients with spinal cord injuries to avoid stimulating the autonomic nervous system and triggering an episode of:
a. paresis. b. heterotopic ossification. c. postural hypotension. d. autonomic dysreflexia.
A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient's insurance form. Which resource should the nurse use to discern the criteria used to establish this diagnosis?
a. The Diagnostic and Statistical Manual of Mental Disorders (DSM) b. Nursing Diagnosis Manual c. A psychiatric nursing textbook d. A behavioral health reference manual