The nurse is performing a postpartum assessment on a client and concludes with the assessment depicted in the figure. Which is the rationale for performing the depicted assessment?
a. Check for edema.
b. Check for range of motion.
c. Check for adequate reflexes.
d. Check for deep vein thrombosis.
ANS: D
Discomfort in the calf with sharp dorsiflexion of the foot is a positive Homans sign and may indicate deep vein thrombosis. Edema is checked by palpating and pressing on the top of the foot, range of motion is not a postpartum assessment, and reflexes are checked at the patellar area.
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The multidisciplinary and standard plans of care for specific case situations have the overall goal of to improve the quality and efficiency of client care. This is an example of:
a. critical pathways c. linear care directories b. goal-oriented care plans d. multidisciplinary action diagrams
Which sign is associated with meningitis and intracranial hemorrhage?
a. Babinski sign b. Asymmetric tonic neck reflex c. Doll's eye movement d. Nuchal rigidity
Tim is a new patient to your mental health unit. He gets your attention, and when the two of you are alone he informs you that he "has the secret to eternal youth
" He offers to tell you, but he is unable to because "they're out there hiding so they can steal it from me. I must be very careful." Your best therapeutic response to Tim is: A) "Tim, I don't see anyone but you and me. It's time for dinner now. I'll walk with you to the dining room." B) "Tim, nobody can have eternal youth. That's not realistic so don't talk about that anymore." C) "I'd love to hear about it, Tim. Tell me your secret." D) "I'll make sure 'they' are all gone, then you can tell me."
____________________ is the most common functional disorder in the elderly.
Fill in the blank(s) with the appropriate word(s).