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ASSAULT
THREATNENING TO PUT NG TUBE FOR NOT EATING or a threat
Things to do prevent safety
complete fall risk assessment, non skid shoes, use gait belts, lock the wheels on the bed/wheel chairs, keep assistive gear nearby (eyeglasses, walkers, transfer devices) , keep the floor clean and dry- clear from rugs/cords, keep bed in lowest position
early stages of hypoxia
confusion, hypertension, restlessness, tachypnea
Weber test?
place the base of a vibrating tuning fork on the top of the clients head
The nurse places a vibrating tuning fork on the top of the head and asks the client if the sound is best in the left or right ear.
Romberg test
helps to see if client has balance the client stands with arms at their side and their feet together
examples of tertiary health care
oncology, burn centers, intensive care
someone who has history of falls what assessment should you take?
Fall risk assessment
when someone is low on oxygen which position should you put them on?
Place the client in semi-Fowler’s or Fowler’s position to promote chest expansion and to maximize ventilation
example of secondary intention wound
3rd pressure stage, open burn
Veracity
the truth
examples of restorative health cares
rehabilitation, skilled nursing facility, and home health care
R.A.C.E?
RESCUE
ALARM
CONFINE
EXTIGUISH
A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions?
Check the position of the cannula frequently.
Report any nausea or difficulty breathing.
Post "No Smoking" signs in prominent locations.
Hypovolemia signs:
Ex: a client who has continuous NG tube suctioning
increased hit , Hyperthermia, orthostatic hypotension, decreased skin turgor, decreased urine output, increased sodium level
skin blanching indicate what in an IV
infiltration?
normal bmi?
overweight bmi?
obesity bmi?
normal - 18.5 - 24.9
Overweight - 25 - 29.9
Obesity 30 higher
PASS?
P- PULL THE PIN
A- AIM AT BASE OF FIRE
S- SQUEEZE THE HANDLE
S - SWEEP THE EXTINGUISHER FROM SIDE TO SIDE
Braden scale
measure six elements
Hypervolomia
EX; someone who has cirrhosis
crackles in the lungs, weight gain, decreased urine gravity
Primary vaccinations for middle adults annually 35-65 years old
influenza immunization, as well as tetanus, diphtheria, zoster, pneumococcal, and pertussis
examples of full liquid
plain yogurt, pudding
someone who has MRSA needs to be in what kind of room?
Private room
DONN PPE
DOFF PPE
gown, mask, goggles, gloves
gloves, goggles, gown, mask
WBC INDICATES?
PLATLETS INDICATE?
Infection
BLEEDING
A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend?
Increase intake of carbohydrate in the diet
Eye examination every 1 to 3 years
DXA screening for osteoporosis
Screening for depressive disorders