In a client with an injury to the medulla, the nurse monitors for which clinical manifestations secondary to damage of cranial nerves that emerge from the medulla? (Select all that apply.)
a. Loss of smell
b. Impaired swallowing
c. Blink reflex
d. Visual changes
e. Inability to shrug shoulders
f. Loss of gag reflex
B, E, F
Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.
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Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.)
a. Checking the circulation to the right hand every 2 hours b. Maintaining a pressurized flush solution to the arterial line setup c. Monitoring the waveform on the monitor for dampening d. Restraining all four extremities with soft limb restraints
All of the following are purposes of evaluation except
a. to promote nursing accountability b. to determine the cost-effectiveness of care c. to determine client progress or lack of progress toward achievement of expected outcomes d. to determine the overall quality of client care provided
The nurse teaches the client hand washing before discharge and asks for a return demonstration. Which client behavior indicates that the client is ready for discharge?
1. Washes hands with running water 2. Washes hands with soap and water 3. Washes hands with very hot water 4. Washes hands in warm, soapy basin
The nurse is providing parental teaching about home care for an 8-year-old boy with widespread sunburn on his back and shoulders. Which response indicates a need for further teaching?
A) "Cool compresses may help cool the burn." B) "He should manually peel off any flaking skin." C) "Nonsteroidal anti-inflammatory drugs like ibuprofen are helpful." D) "He should avoid hot showers or baths for a couple of days."