When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient’s posturing as a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

When the nurse observes that the patient has extension and
external rotation of the arms and wrists and extension, plantar
flexion, and internal rotation of the feet, she records the patient’s
posturing as
a) decerebrate.
Decerebrate posturing is the result of lesions at the midbrain and is
more ominous than decorticate posturing.
b) normal.
The described posturing results from cerebral trauma and is not
normal.
c) flaccid.
The patient has no motor function, is limp, and lacks motor tone with
flaccid posturing.
d) decorticate.
In decorticate posturing, the patient has flexion and internal rotation
of the arms and wrists and extension, internal rotation, and plantar
flexion of the feet.
by

1 Answer

Answer :

a) decerebrate.
Decerebrate posturing is the result of lesions at the midbrain and is
more ominous than decorticate posturing.
by

Related questions

When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

Description : When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not ... Paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Last Answer : a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

Description : When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. ... the result of increased interstitial fluid and associated with disorders such as congestive heart failure.

Last Answer : a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

Description : When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi's sarcoma. Kaposi's sarcoma is ... syphilis. A painless chancre or ulcerated lesion is a typical finding in the patient with syphilis.

Last Answer : a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when a) the vesicles and pustules have crusted. When the lesions have crusted, the patient is no longer contagious to others.

Description : The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when a) the vesicles and pustules have crusted. When the lesions have crusted, the ... , and pustules appear. The child remains contagious when the rash is changing into vesicles and pustules.

Last Answer : a) the vesicles and pustules have crusted. When the lesions have crusted, the patient is no longer contagious to others.

When the patient’s eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Description : When the patient's eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell ... d) normal. Eosinophils normally make up 1-3% of the total number of white blood cells.

Last Answer : a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

When the nurse notes that the patient’s left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) hammertoe. Hammertoes are usually pulled upward. c) pes cavus. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Last Answer : a) hallux valgus. Hallux valgus is commonly referred to as a bunion.

What types of exercise are plantar flexions hip extension knee flexion and side leg raises?

Description : What types of exercise are plantar flexions hip extension knee flexion and side leg raises?

Last Answer : You lift the weight on your shoulder, behind the neck. Lift yourself by planer flexing the feet. You put the chest expander on thewall and press them downwards with your heels, when you ... separatethe straight legs apart. Alternately fix some weight to your footand do the side leg rise exercise.

When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. b) must be equal in both arms. The pressures in each arm do not have to be equal in order to be considered normal. c) may vary 10 mm Hg or more between arms. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. d) may vary, with the higher pressure found in the left arm. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Description : When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in ... . The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Last Answer : a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.

70. The senior nurse observes that Marina occasionally does not follow agreed upon interventions. The senior nurse reports that Marina should improve in which of the following?

Description : 70. The senior nurse observes that Marina occasionally does not follow agreed upon interventions. The senior nurse reports that Marina should improve in which of the following?

Last Answer : C. Compliance to standards

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

The nurse reading the physician’s report of an elderly patient’s physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

Description : The nurse reading the physician's report of an elderly patient's physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is ... red moles. Cherry angioma is the term that is used to describe a bright red mole.

Last Answer : a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Description : Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient's level of anxiety has decreased? a) Answers questions regarding status with ... in support groups. Participation in support groups indicates some degree of comfort with prognosis.

Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient’s serum electrolytes anticipating which abnormality? a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). b) Hypercalcemia Hypercalcemia would likely be demonstrated by asystole. c) Hypomagnesemia Hypomagenesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. d) Hyponatremia Hyponatremia would likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Description : When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hyperkalemia ... likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Last Answer : a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves).

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

During which step of the nursing process does the nurse analyze data related to the patient’s health status? a) Assessment Analysis of data is included as part of the assessment. b) Implementation Implementation is the actualization of the plan of care through nursing interventions. c) Diagnosis Diagnosis is the identification of patient problems. d) Evaluation Evaluation is the determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved.

Description : During which step of the nursing process does the nurse analyze data related to the patient's health status? a) Assessment Analysis of data is included as part of the assessment. b) ... patient's responses to the nursing interventions and the extent to which the outcomes have been achieved.

Last Answer : a) Assessment Analysis of data is included as part of the assessment.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. b) 30-35 seconds Applying suction for 30-35 seconds is hazardous and may result in the patient’s developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest.

Description : When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general ... suction for 0-5 seconds would provide too little time for effective suctioning of secretions.

Last Answer : a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest.

When the nurse auscultates chest sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together, she records her finding as a) pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. b) crackles. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. c) sonorous wheezes. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. d) sibilant wheezes. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

Description : When the nurse auscultates chest sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together, she records her finding as a) pleural friction rub. A ... wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

Last Answer : a) pleural friction rub. A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid.

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

Description : When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person ... 20/20 line, the person of normal vision will be standing at a distance of 20 feet from the chart.

Last Answer : a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

In order to help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be to use a) a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip. b) pillows under the lower legs. Pillows under the legs will not prevent the hips from rotating externally. c) a hip-abductor pillow. A hip-abductor pillow is used for the patient after total hip replacement surgery. d) a footboard. A footboard will not prevent the hips from rotating externally.

Description : In order to help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be ... hip replacement surgery. d) a footboard. A footboard will not prevent the hips from rotating externally.

Last Answer : a) a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip.

Which of the following statements reflects information to be included when teaching the patient about plantar fasciitis? a) Management of plantar fasciitis includes stretching exercises. Management also includes wearing shoes with support and cushioning to relieve pain, orthotic devices (e.g., heel cups, arch supports), and the use of non-steroidal anti-inflammatory drugs (NSAIDs).

Description : Which of the following statements reflects information to be included when teaching the patient about plantar fasciitis? a) Management of plantar fasciitis includes stretching exercises. ... Complications of plantar fasciitis include neuromuscular damage and decreased ankle range of motion.

Last Answer : a) Management of plantar fasciitis includes stretching exercises. Management also includes wearing shoes with support and cushioning to relieve pain, orthotic devices (e.g., heel cups, arch supports), and the use of non-steroidal anti-inflammatory drugs (NSAIDs).

In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

Description : When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test ... When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.

Last Answer : a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi-mushy. With a descending colostomy, the feces are semi-mushy. c) mushy. With a transverse colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Description : The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi- ... colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Last Answer : a) solid. With a sigmoid colostomy, the feces are solid.

When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which of the following electrolyte imbalances? a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

Description : When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects ... and QT intervals, broad flat T waves), disorientation, depression, and hypotension.

Last Answer : a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity. b) Vital capacity The nurse anticipates decreased vital capacity. c) Gas exchange and diffusing capacity The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. d) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Description : When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue ... ) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Last Answer : a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity.

A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Description : A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Last Answer : A. Write and submit an explanation and reprimand as necessary

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Lesions in the temporal lobe may result in which of the following types of agnosia? a) Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia.

Description : Lesions in the temporal lobe may result in which of the following types of agnosia? a) Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia. ... Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia.

Last Answer : a) Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia.

Dupuytren’s contracture causes flexion of the a) fourth and fifth fingers. Dupuytren’s contracture causes flexion of the fourth and fifth fingers, and frequently the middle finger.

Description : Dupuytren's contracture causes flexion of the a) fourth and fifth fingers. Dupuytren's contracture causes flexion of the fourth and fifth fingers, and frequently the middle finger. b) thumb. ... Dupuytren's contracture causes flexion of the fourth and fifth fingers, and frequently the middle finger.

Last Answer : a) fourth and fifth fingers. Dupuytren’s contracture causes flexion of the fourth and fifth fingers, and frequently the middle finger.

Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion that will increase ICP.

Description : Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous ... an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

Last Answer : a) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion that will increase ICP.

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) normal. Normal bowel sounds are heard every 5-20 seconds. b) hypoactive. Hypoactive bowel sounds is the description given to auscultation of one to two bowel sounds in 2 minutes. c) sluggish. Sluggish is not a term a nurse would use to accurately describe bowel sounds. d) absent. The nurse records that bowel sounds are absent when no sound is heard in 3-5 minutes.

Description : When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) normal. Normal bowel sounds are heard every 5-20 seconds. b) hypoactive. Hypoactive bowel sounds ... absent. The nurse records that bowel sounds are absent when no sound is heard in 3-5 minutes.

Last Answer : a) normal. Normal bowel sounds are heard every 5-20 seconds.

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

Description : The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression ... contraindicated when injury is suspected, and examination, while indicated, does not provide treatment.

Last Answer : a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

94. When Nurse Abe presents the patient’s chart as evidence of a case, this is called a/an

Description : 94. When Nurse Abe presents the patient’s chart as evidence of a case, this is called a/an

Last Answer : C. Exhibit

93. When the nurse is called to witness and was told to bring the patient’s chart, what is needed to legally summon the client’s chart in court?

Description : 93. When the nurse is called to witness and was told to bring the patient’s chart, what is needed to legally summon the client’s chart in court?

Last Answer : D. Subpoena from the judge

A patient has had neurologic deficits lasting for more than 24 hours, and now the symptoms are resolving. The nurse concludes that the patient has had which type of stroke? a) Reversible ischemic neurologic deficit With a reversible ischemic neurologic deficit, the patient has more pronounced signs and symptoms that last more than 24 hours; symptoms resolve in a matter of days without any permanent neurologic deficit.

Description : A patient has had neurologic deficits lasting for more than 24 hours, and now the symptoms are resolving. The nurse concludes that the patient has had which type of stroke? a) Reversible ... and symptoms have stabilized with no indication of further progression of the hypoxic insult to the brain.

Last Answer : a) Reversible ischemic neurologic deficit With a reversible ischemic neurologic deficit, the patient has more pronounced signs and symptoms that last more than 24 hours; symptoms resolve in a matter of days without any permanent neurologic deficit.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

Description : When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the ... or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Last Answer : a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Description : Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the ... term home IV therapy (eg, Port A Cath, Mediport, Hickman Port, P.A.S. Port).

Last Answer : a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Description : Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and ... only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

Last Answer : a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.