The nurse is preparing to assess a patient's neurologic system. What should the nurse do to assess sensory function?
A. Have the patient distinguish which parts of the body are being touched.
B. Write a number on the patient's hand and have him or her identify the number.
C. Ask the patient to identify two areas of simultaneous pinpricks on the hand.
D. Touch both sides of various parts of the body with a sharp and a dull object.
Answer: D
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A mother brings her 4-month-old in for an exam because he has been vomiting for 12 hours. Which of the following is a good assessment of hydration status?
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A client's nasogastric tube has been discontinued and needs to be removed. Place in order the steps the nurse will perform to remove this tube
1. Place the tube in a plastic bag. 2. Ask the client to take a deep breath and to hold it. 3. Smoothly withdraw the tube. 4. Pinch the tube with the gloved hand. 5. Observe the intactness of the tube. 6. Apply clean gloves.
Which of the following nursing actions is most likely a result of the nurse's clinical experience?
1. Placing an immobile client on a turning schedule 2. Always assessing a client's IV site before hanging a new bag of fluid 3. Requesting that the nursing assistant have vital signs recorded by 0815 4. Administering a pain medication 30 minutes before changing a burn dressing