The nurse is caring for a client after a motor vehicle accident (MVA) and instructs the client to avoid turning because the client's spine is unstable
Which does the nurse use to explain the purpose of the safeguards in relation to the client's injury? 1. Prevents a sudden deterioration in vital signs
2. Keeps the neck and spine in straight alignment
3. Facilitates efficient, comprehensive assessment
4. Helps to maintain straight alignment of the legs
2
2. The nurse does not allow the client to turn to the side as an unstable spine cannot maintain normal alignment because the integrity of one or more vertebrae is disrupted. If the client moves, the client risks exacerbating the spinal cord injury by abnormal movements of vertebral bone fragments. To maintain client safety, the nurse turns the client with logrolling and thereby keeps the head, neck, and spine in straight alignment thus preventing bone fragments from shifting and potentially increasing the damage.
1 and 3. Keeping the client in the supine position is ideal for maintaining hemody-namic stability and facilitating assessments.
4. Logrolling helps to maintain leg alignment, but the primary purpose of logrolling is to maintain alignment of the neck and spine.
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Which statement describes functional nursing?
1. One nurse has responsibility for all the needs for three clients. 2. One nurse has responsibility for all the medications on the unit. 3. One nurse and one nursing assistant have responsibility for ten clients. 4. One charge nurse and one respiratory therapist have responsibility for all clients.
An elder Hispanic patient in progressive shock lingers on the verge of death. The nurse must understand some of the cultural influences of the family, and the patient must be especially respected at this time
In general, the patient's cultural background dictates that the medical team should: 1. allow any and all cultural rituals. 2. remind the family that the patient can be comforted by their familiar voices. 3. restrict the ministrations of the folk healer. 4. suggest that small children not see the patient.
Which action should the nurse take first when a patient develops a nosebleed?
a. Pinch the lower portion of the nose for 10 minutes. b. Pack the affected nare tightly with an epistaxis balloon. c. Obtain silver nitrate that will be needed for cauterization. d. Apply ice compresses over the patient's nose and cheeks.
A community health nurse attempts to provide care to homeless clients at a local shelter. One of the major problems in attempting to provide health care services to the homeless is:
A) Most of them do not want help. B) They are suspicious of anyone who offers help. C) Most are proud and will refuse charity. D) They have a penchant for mobility.