We have to know this?
Difference between subjective and objective data?
subjective-patient states
objective- observed
You are bathing a male client. Which actions by the student nurse suggest further teaching is needed? Replacing the foreskin on uncircumcised patient, place patient reverse Trendelenburg, place the patient supine with pillows for support; wash all areas beginning with the urinary meatus
place the patient reverse Trendelenburg
The nurse is scheduling a conference about the use of restraints. The nurse notes that it is important to include which of the following as correct use?
Tie restraints to the lower arm rails
lying patient complete supine with wrist restraints to the headboard
ensuring no more than 2 finger breaths underneath wrist restraint
obtain a order every 24 hours and loosen restraints every 4 hours
ensuring no more than 2 finger breaths underneath wrist restraints
A small group of students are bathing a patient with Alzheimer's disease. What actions taken by the students suggests a correct understanding of bathing this client? using distraction such as calming music may help with bathing; brush firmly from the feet to the shoulders; the family are required to assist with bathing; bathing as quickly as possible in visible areas only to avoid agitation
using distraction such as calming music may help with bathing
Cleaning area floor rugs clean
Walking barefoot to have the best grip to the floor
Performing safety rounds every 1 hour, keeping items close in reach
having the IV pole on the opposite side of the line placement
performing safety rounds every 1 hour, keeping items close in reach
This is considered a primary source of information
patient
destructive to self and others despite interventions
Name a priority nursing education for diabetic patients?
take all medications, keep feet clean, wear shoes or non-skid socks, should not walk barefoot
The nurse notes which patient is at the greatest risk for falls:
The 78 year old patient hard of hearing
The 71 year old patient with urinary frequency
The 64 year old patient with COVID
The 58 year old patient one day postoperative being assisted to the chair
the 71 year old patient with urinary frequency
You are assessing an elderly client who has been neglected at his current nursing home. He appears disheveled and underweight. Which nursing diagnosis below would be appropriate for this client?
Activity intolerance
Decreased Cardiac Output
Self Care Deficit
Impaired Gas Exchange
Self Care Deficit
Select all that a apply. The nurse is planning on moving the patient from bed to chair. He/she uses which methods to protect their back from injury? Mechanical lift, additional staff assistance if necessary, wearing a back brace and bending at the waist, placing feet close to together and bending at the knees
Mechanical lift, additional staff assistance if necessary
Your patient is occasionally confused, what is an effective clinical judgement to ensure safety? Perform tasks one at a time using a walker while ambulating if necessary; give the patient a time limit to complete tasks so as to not become agitated; performing a full bath; have family members be solely in charge of patient care
perform tasks one at a time using a walker while ambulating if necessary
List one helpful hint to ensure safety in the elderly population
remove throw rugs, proper lighting, keep items close in reach, non slip footwear
In this stage of ADPIE, the nurse processes whether the goals were effective and if changes are necessary
evaluation
The nurse is teaching a group of newly graduate students about properly bathing clients. Which statement suggests a correct understanding?
It is recommended to use this time to assess skin
Patients should be bathed every 2 days and PRN given elimination status
Partial bed bath should be performed on patients who are mobile
Bed baths should be performed regardless of their ability to perform self care
It is recommended to use this time to assess skin
reviewing the client's previous discharge notes
obtaining a health history and labs
reviewing provider's orders
asking the client questions about their Parkinson's disease
asking the client questions about their Parkinson's disease
The nurse is caring for a client who has a nursing diagnosis of impaired gas exchange due to recent exacerbation of asthma. The nursing diagnosis falls under which of the following categories according to Maslow's hierarchy of needs?
Safety and security
Love and Belonging
Self Care
Psychological Needs
Psychological Needs
In response to a seizure, the nurse notes which action made ensures the correct understanding of safety precautions?
Tilting the chin down to the chest and lie the patient supine
Head tilt, chin lift, and turn patient to right lateral
Having an AED
Keep sharp objects close in reach in case restraints need to be cut
Head tilt chin lift and turn patient the right lateral
The nurse is caring for a patient with a spinal cord injury. By which method is best practices when bathing a patient? restrained, chin tuck, logroll with assistance, bend leg and turn with assistance
logroll with assistance