The nurse of a bedridden 74-year-old woman is evaluating whether ...

[HudsonKB16]

The nurse of a bedridden 74-year-old woman is evaluating whether the family members understand how to position the patient correctly. The nurse is confident the family is capable of effective positioning when it is observed that the patient's
 
  a. arms and legs are supported on two pil-lows.
  b. position is changed at least every 2 hours.
  c. neck is hyperflexed.
  d. elbows rest on the bed.

Question 2

A patient in a nursing home is confused, nonverbal, but pleasant
 
  The nurse notes the patient has suddenly become agitated and is screaming and scratching at the eyes. While the nurse is ex-amining the patient, the patient vomits. What action by the nurse is best?
  a. Consult the provider about an ophthalmo-logic exam.
  b. Sedate the patient so she won't injure herself.
  c. Place mitts on the patient's hands to avoid scratches.
  d. Give the patient a prn medication for pain.

[spencer.martell]

Answer to Question 1

B
In the 1950s, Kosiak (1958) found that pressure applied to rabbits' ears over 2 hours would result in ulceration. Thus, the universal recommendation of turning every 2 hours was established. The other observations do not show the family necessarily understands effective positioning if the patient is not turned.

Answer to Question 2

A
The patient could be having an episode of acute angle closure glaucoma, manifested by severe pain, nausea and vomiting, and visual disturbances. Because the patient is nonverbal, the nurse must assess for pain with behavioral changes. The nurse should contact the provider about ob-taining an ophthalmologic exam to determine if the patient has glaucoma. The other interventions will not help determine the cause of the problem. The nurse should attempt to discover the source of the behavior, not just try to control it.

[HudsonKB16]

TYSM

[Jossy]

Gracias!