A client has arrived by ambulance at the emergency department after a cervical spinal cord injury. Which assessment is a priority for the nurse to perform at this time?
A. Assessment of mental status
B. Assessment of heart rate and rhythm
C. Assessment of muscle strength and reflexes
D. Assessment of respiratory pattern and airway
D
The first priority for a client with a spinal cord injury is assessment of respiratory status and air-way patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. Priority nursing diagnoses include Ineffective Airway Clearance, Ineffective Breathing Pattern, and Impaired Gas Exchange.
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A client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout?
A) Elevated white blood count B) Elevated uric acid levels C) Decreased hemoglobin and hematocrit D) Increased AST and ALT
A person desires to bring suit for injuries sustained while hospitalized. What is this person's legal burden of proof?
1. To show that an incident occurred during the hospitalization 2. To show that injuries were sustained 3. To show that an incident occurred and resulted in injury 4. To show that an incident occurred causing injury and that the incident was intentional
Which of the following assessment findings would lead the nurse to suspect that a patient has Bell's palsy?
A) Inability to detect sharp and dull stimuli B) Inability to wrinkle the forehead C) Closure of the affected eye from swelling D) Muscle spasm of the lower face on the affected side
The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." This statement describes the client's:
A. feelings. B. blocking. C. mood. D. affect.