The nurse is assessing a client's remote memory. Which statement by the client confirms that remote memory is intact?
a. "Mary had a little lamb whose fleece was white as snow."
b. "I was born on April 3, 1967, in Johnstown Community Hospital."
c. "Apple, chair, and pencil are the words you just stated."
d. "My sister brought me to the clinic for this appointment."
B
Asking clients about certain facts from the past that can be verified assesses remote, or long-term, memory. The client's ability to make up a rhyme tests not memory, but rather a higher level of cognition. The other statements indicate immediate and recent memory.
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The nurse is administering packed red blood cells to a child with sickle cell disease. The nurse knows that a transfusion reaction is most likely to occur:
1. 6 hours after the transfusion is given. 2. Within the first 20 minutes of administration of the transfusion. 3. At the end of the administration of the transfusion. 4. Never. Blood reactions to transfusions do not occur.
The rectovaginal examination is an important component of the total pelvic examination because it:
a. is the most direct cervical examination route. b. is a more comfortable examination for the posthysterectomy patient. c. is an alternate source for cytology speci-mens. d. allows the examiner to reach almost 2.5 cm higher into the pelvis.
A nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. When planning health promotion strategies, what factor should the nurse take into consideration?
1. Rest and exercise 2. Adjusting to physiologic changes and limitations 3. High obesity percentages 4. Safety promotion and injury prevention
The graduate nurse is thinking about leaving a new job because of actions demonstrated by the nurse manager. Which actions should the graduate nurse identify as bullying?
1. Pairing the graduate with a seasoned nurse to assist with learning new skills 2. Asking the graduate to participate in client rounds with the new interns on the care area 3. Confronting the graduate by stating that refusing an assignment is grounds for dismissal 4. Stating that requests for vacation time will be denied because the nurse asks too many questions 5. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing