A nurse is about to admit a client to the ICU after the client suffered a head injury in a motor vehicle accident. Which of the following will the nurse frequently monitor?
a. level of conscious-ness e. vital signs
b. pupil changes f. Glascow Coma Scale
c. pulse oximetry g. bowel elimination
d. intake and output
A, B, C, D, E, F
A client post injury will need to be monitored frequently to assess for changes in neurological status. The clinical assessment should include: frequent assessment of neurological status, including level of consciousness, motor function, eye movement, pupil size and reaction, protective reflexes, and vital signs, allows for early recognition of and intervention for increasing intracranial pressure.
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A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:
a. Speak loudly so the patient can hear the questions. b. Assess for middle ear infection as a possible cause. c. Ask the patient what medications he is currently taking. d. Look for the source of the obstruction in the external ear.
A client is recovering from cochlear implant surgery. What is true regarding cochlear implants?
A) They restore normal hearing to those who could not hear any sound prior to implantation. B) Their function is more similar to the way the ear normally receives and processes sounds than it is to that of a hearing aid. C) They may be the only hope for restoring sound perception for the client with a total and permanent hearing loss. D) With implantation, the structures of the middle ear are reconstructed to improve conductive hearing deficits.
You are caring for a patient when another nurse assistant approaches you and wants you to come and see something. As you follow her, she gets to a patient's room and starts to open the door without knocking. She then tells you a resident married couple of the facility are being intimate. She is snickering and says, "I didn't think it was possible at their age." What do you do?
What will be an ideal response?
What interventions will facilitate maintaining A.N.'s peripheral tissue perfusion?
What will be an ideal response?