The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will

instruct the patient to remain on strict bed rest

provide the patient with additional blankets"

encourage the patent to increase his muscle activity”

offer fluids to the patient if permitted

Answer and Explanation

The Correct Answer is C

A.   Keeping the patient on bed rest is appropriate as it conserves energy and helps prevent further heat loss.
B.   Providing additional blankets is a correct intervention to warm the patient gradually.
C.   Increasing muscle activity is contraindicated because it could cause vasoconstriction and worsen hypothermia, as the body focuses on preserving core temperature.
D.   Offering fluids (if permitted) is correct as hydration can help restore normal body temperature regulation.

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Correct Answer is D

Explanation

A. A score of 7 would indicate a much lower level of consciousness and require urgent intervention.
B. A score of 12 would indicate some level of impairment, with the patient not fully alert or responsive.
C. A score of 10 would indicate some level of impairment, with the patient not fully alert or responsive.
D. A score of 15 on the Glasgow Coma Scale indicates full consciousness and normal neurological function. It is the highest possible score, reflecting a patient who is awake, aware, and able to follow commands.

A. dialysis shunt. B. 2-year-old hand amputation. C. previous mastectomy. D. patent IV line.

Correct Answer is ["A","C"]

Explanation

A. A dialysis shunt requires careful monitoring to avoid damaging the shunt, and blood pressure cuffs should not be applied to the arm with a shunt.
B. A hand amputation does not affect the use of the blood pressure cuff, but care should be taken with the affected area.
C. A previous mastectomy increases the risk of lymphedema, and using a blood pressure cuff on the affected arm could exacerbate this.
D. A patent IV line is not a contraindication for blood pressure measurement, but the nurse should take care not to interfere with the IV.

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The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of

Correct Answer is D

Explanation

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)

Correct Answer is ["A","C"]

Explanation

When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)

The nurse taking a blood pressure should:

A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/84 mm Hg places him in which of the following categories?

The nurse covers a newborn baby's head with a cap. because the head:

A very pertinent part of the physical examination on a patient with back pain is

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

The normal pattern of breathing is described as