An older patient who is dying is unable to fully close the eyes. What can the nurse do to protect the patient's eyes from irritation?
1. Apply eye guards.
2. Apply artificial tears.
3. Tape the eyes closed.
4. Reduce the room lighting.
2
Rationale: Eye guards are not used to protect the eyes of a dying patient from drying out.
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Percussion is a useful examination technique to determine the size, shape, and position of organs as well as to
a. determine the density (air, fluid, or solid) of a structure. b. detect an abnormal deep mass (over 5 cm deep). c. listen to body organs to gather information on the patient's clinical status. d. determine the skin moisture and texture with your hands.
The health care provider is assessing a patient who was recently prescribed loxapine (Loxitane). Which of the following symptoms would indicate that this patient is experiencing the adverse effect of dystonia?
a. Lip smacking b. Tongue thrusting c. Shuffling gait d. Movement of eyeballs upward
The nurse recognizes that clients admitted to the unit are associated with nationwide demographic trends. Which statement supports this observation?
1. Diabetes is most prevalent in the Caucasian community. 2. Hispanic patients have a greater incidence of obesity. 3. African-American patients have a lower incidence of hypertension. 4. Caucasians are more likely than African Americans to have limitations with ADLs when chronically ill.
Marc is a 5-year-old who has attention deficit hyperactivity disorder. He is taking Ritalin, a stimulant. The nurse should teach Marc's caregiver: (SELECT ALL ANSWERS THAT APPLY)
A) There are very few side effects and no particular nursing considerations. B) Tolerance, insomnia, and dependence can occur with this medication. C) It is OK to stop this drug immediately if any side effects are noted. D) Marc should be observed for suicidal ideation. E) Marc is likely to have an increased appetite. F) Hypotension is a potential side effect of the medication.