The nurse is turning a client from her back to her side. To promote safety and the client's proper body alignment, the nurse: Standard Text: Select all that apply
1. Ensures the bed is clean and dry.
2. Places support devices in specified areas.
3. Places body parts on top of each other to ensure alignment.
4. Plans a 24 hour schedule for position changes.
5. Ensures the mattress is soft.
1,2,4
Rationale: Wrinkled or damp sheets increase the risk of pressure ulcer formation.
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Which instruction is most helpful in teaching the family and patient who is in the rehabilitation phase after a CVA about altered sensation?
a. Make frequent assessments for signs of pressure or injury. b. Use the affected side in supporting the patient in ambulation and transfer to sti-mulate better sensation. c. Apply ice packs to the affected limbs to encourage a return of sensation. d. Apply a heating pad to the affected limbs to increase circulation.
A parent was recently hospitalized with severe depression. Family members say, "We're falling apart. Nobody knows what to expect, who should make decisions, or how to keep the family together."
Which interventions should the nurse use when working with this family? Select all that apply. a. Help the family set realistic expectations. b. Provide empathy, acceptance, and support. c. Empower the family by teaching problem solving. d. Negotiate role flexibility amongst family members. e. Focus planning on the family rather than on the patient.
Which situation below best depicts a mid-life crisis?
a. A 22-year-old college graduate moves in with her parents because she cannot find employment. b. The parents enroll their two toddlers in day care because two incomes are needed to meet the household's financial demands. c. After the couple's daughter leaves for college, the husband quits his job and decides to "see the world." d. A 70-year-old widower rejects the children's advice to move into an assisted living facility.
The nurse in the emergency department phones to tell you that J.O.'s immunization status could not be
determined when he arrived, so no tetanus immunization was given. When you ask J.O. the date of his last tetanus shot, you find out that he was born and raised in Colombia and immigrated to the united States 5 years ago. He does not know whether he has ever had a tetanus shot. You inform the physician, and he orders diphtheria/tetanus toxoid 0.5 mL IM and tetanus immune globulin (HyperTET) 250 units deep IM. Why is J.O. getting two injections?