Which is a restraint?
a. A chair with an attached tray table
b. A rocking chair
c. A reclining chair
d. A low bed
A
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The assessment of bulging flanks on a patient who is supine with knees flexed leads the nurse to assess further for:
a. ascites. b. bowel obstruction. c. liver disorder. d. gallstones.
The nurse instructs the client and family to observe for client hypoxia during home oxygen therapy. Which is the most important clinical indicator of hypoxia that the nurse instructs the family to monitor?
1. Confusion 2. Dusky lips 3. Tachypnea 4. Restlessness
Which technique is used with intramuscular drug injections but not with intradermal drug injections?
a. Ensuring the site selected is appropriate for injection b. Cleansing the selected site before inserting the needle c. Aspirating the syringe before injecting the drug solution d. Checking for allergic or sensitivity reactions to the injection
Penny Williams, a 74-year-old patient, is admitted to the telemetry unit with the diagnosis of acute ischemic stroke. The patient is experiencing paroxysmal atrial fibrillation with a controlled ventricular rate on the monitor. The CT of the head without contrast reveals no evidence of hemorrhage. The transesophageal echocardiogram reveals moderate mitral valve insufficiency and embolism as a primary cause of the stroke. The patient is on a weight-based heparin protocol. The patient received digitalis to keep the ventricular rate of the atrial fibrillation controlled. The patient has right-sided paralysis and global aphasia. The patient has unilateral neglect of her right side and has right field homonymous hemianopsia. There is papilla edema present bilaterally.
The patient is drooling from the right side of her mouth and coughs periodically. The patient was found by her daughter after her daughter had gotten out of work and arrived at her mother’s home. The daughter stated her mother was normal before she left for work, and 10 hours later the mother exhibited the symptoms described above. The time of onset for the stroke could not be safely determined so no interventions could be used to treat the stroke. What principles of nursing management should the nurse provide the patient during the acute stage of the ischemic stroke based on the assessment findings from the case study? Place the assessment findings that are supported by the nursing principle(s) in parenthesis.