After completing rounds, the physician prescribes restraints for four patients on the floor. Upon reviewing the orders, the nurse knows that it's inappropriate to apply restraints to which of the following patients?
A) A postlaryngectomy patient attempting to pull out his tracheostomy tube
B) A patient in hypovolemic shock trying to pull out his IV catheter
C) A patient with urosepsis who rings the call bell often to use the bedside commode
D) A paranoid patient who has just tried to commit suicide and is refusing restraints
Ans: C
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During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate?
a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.
You are the nurse caring for a patient who is immobile due to a hunting accident. You know to assess for the development of pressure ulcers on this patient. Why would you know to do this?
A) You know that this patient will be immobile only until the cast comes off. B) You know that this patient has a lot of support in maintaining proper alignment. C) You know that the risk for pressure ulcers is directly related to the duration of immobility. D) You know that the risk for pressure ulcers is related to what caused the immobility.
The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?
a. Blood pressure (BP) 92/56 mm Hg b. Skin cool and clammy c. Oxygen saturation 92% d. Heart rate 118 beats/minute
What does it mean when a drug is described as easy to administer?
a. It can be stored indefinitely without need for refrigeration. b. It does not interact significantly with other medications. c. It enhances patient adherence to the drug regimen. d. It is usually relatively inexpensive to produce.