A nurse assesses a postoperative patient's level of consciousness and documents the following: the patient opens eyes spontaneously when someone approaches, accurately responds to instructions, converses, and is oriented to time, place, and person
What number would this patient receive on the Glasgow Coma Scale?
A) 20
B) 15
C) 10
D) 5
B
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You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias
The patient has a history of congestive heart failure and peptic ulcer disease. The patient is refusing to ambulate and will not drink fluids except for hot tea with her meals. The nurse's aide reports to you that this patient's vital signs are slightly elevated and she has a nonproductive cough. When you assess the patient, you find there are crackles at the base of the lungs. What would you suspect is wrong with your patient? A) Flash pulmonary edema B) Pneumonia C) Hypostatic pulmonary congestion D) Right-sided heart failure
A client develops aspiration pneumonia after a traumatic brain injury produced an impaired ability to swallow. Which activity should the nurse skip when caring for this client?
a. Nutrition history b. Nutrition screening c. Head-to-toe physical assessment d. Laboratory-based diagnostic testing
An older client has several small vesicles with eroded centers on the lips. What is the first action for the nurse to perform?
1. Notify the healthcare provider of the lip vesicles. 2. Document the assessment findings in the medical record. 3. Teach the client to perform careful hand washing. 4. Review the client's temperatures and white blood cell count.
Dante, a fifth grader, has come to the school nurse's office because he has a stomachache. The nurse assesses Dante and sees no physiological reason for a stomachache
The nurse attempts to send him back to class, but Dante asks if he can stay until after the spelling test. The nurse knows: 1. Dante is attempting to avoid the exam because of fear of failure. 2. Dante needs more time to rest. 3. Dante knows he will not get better and needs to go home. 4. Dante is worried he will get sick in the classroom.