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The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle Answer: 2. Nail bed pressure Rationale: Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbi...

A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? 1. "Come to the emergency department." 2. "Apply calamine lotion immediately to the exposed skin areas." 3. "Take a shower immediately, lathering and rinsing several times." 4. "It is not necessary to do anything if you cannot see...

1. A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse include in the plan? a) Ask the client to tilt their head back when swallowing. b) Have the client sit upright for 1 hr. following meals. c) Administer liquids to the client using a syringe. Allow the client to rest for 10 min prior to eating

1. A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect? a. Reports increased urinary output b. Diaphoresis c. Reports blurred vision d. Shallow respirations

1. Appropriate nursing actions: Nicole a) When a client falls • 1st priority – check on patient for any injuries Before that, guide the patient to the floor. b) Positioning to reduce injury for bony prominences • Place pillows under areas and elevate • Changes position for 2hrs Elevate calves to protect heels c) Reducing shear injury (med surg pg 447) • Avoid pulling and sliding patient against bed • Keep head of bed at a slight elevation • Make sure sheets and...

1. The effects of Immobility a) Interventions that improve flexibility • P.R.E.P.(Perform passive ROM, Reposition Q2HR, Encourage independent activity as much as possible even in bedrest, Provide assistive devices) • Know examples of exercises for flexibility b) Assessment/ Findings of a patient with DVT • Assessment (1) Compare distal pulses for pulse quality, observe the color and temp. of extremities, evaluate sensation and motion, and determine speed of capillary refill. Compare ...

No areas of dullness Dullness, anterior right upper lobe Dullness, anterior right middle lobe Dullness, anterior right lower lobe Dullness, anterior left upper lobe Dullness, anterior left lower lobe Dullness, posterior right upper lobe Dullness, posterior right lower lobe Dullness, posterior left upper lobe Dullness, posterior left lower lobe

So, three days ago, at around 0630 hours, Dr. Douglas slipped and fell while she was alone at home. She felt a sharp pain and knew something was wrong. She couldn't get to her phone, so she held still and waited for her husband to come home. At 0800 hours, Dr. Douglas reported at our Emergency Department with pain in her groin and inability to support weight. She had an open reduction and internal fixation at 1200 hours. At 1700 hours that day, she was moved here to Med-Surg for post-opera...

NURS 224 Assignment 2_Delegation _Completed_Shadow Health Prioritizing Delivery of Care -Johns Hopkins University

NURS 224 Assignment 2_ Delegation _ Completed _ Shadow Health Team Delegation - Johns Hopkins University