The nurse is caring for a patient who has been diagnosed with a stroke. As part of her ongoing care, the nurse should
a. Encourage the patient to perform as many self-care activities as possible.
b. Provide a complete bed bath to promote patient comfort.
c. Place the patient on bed rest to prevent fatigue.
d. Understand that the patient will not eat owing to a decreased energy need.
ANS: A
Nurses should encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. Anorexia and insufficient assistance with eating lead to malnutrition.
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A nurse is caring for a patient with an atrioventricular (AV) fistula in the forearm and assesses that a trill is absent when palpating the venous side of the fistula. What action should the nurse implement?
a. Inject the ordered amount of heparin into the fistula. b. Apply warm compresses and lower the arm below the heart level. c. Send the patient to dialysis for remedy. d. Report to the charge nurse that the fistula is occluded.
What factor is most important in predisposing toddlers to frequent infections?
a. Respirations are abdominal. b. Pulse and respiratory rates in toddlers are slower than those in infants. c. Defense mechanisms are less efficient than those during infancy. d. Toddlers have short, straight internal ear canals and large lymph tissue.
A patient prescribed carbidopa/levodopa (Sinemet) for Parkinson's disease may experience a decrease in absorption of the drug if on a high- ________ diet.
Fill in the blank(s) with the appropriate word(s).
While providing care for a patient who has recently completed chemotherapy for colorectal cancer, the nurse notes the patient has an elevated carcinoembryonic antigen (CEA) level
Which of the following interpretations of this test result, by the nurse, is best? a. The patient has a residual or recurrent tu-mor. b. The liver has been damaged by chemo-therapy. c. The patient is cured. d. The patient should be placed in protective isolation.