Author Question: Which of these statements would be most appropriate for a nurse to state when assessing an adult ... (Read 26 times)

azncindy619 · **on:** Jul 22, 2018

Which of these statements would be most appropriate for a nurse to state when assessing an adult patient for growth and developmental delays?

a. How many times per week do you exercise?
b. Are you able to stand on one foot for 5 seconds?
c. Would you please describe your usual activities during the day?
d. How many hours a day do you spend watching television or sitting in front of a computer?

Question 2

The unconscious patient is resisting attempts by the nurse to provide oral hygiene. To provide the needed care, the nurse may

a. Insert an oral airway upside down.
b. Hold the patient's mouth open with her fingers.
c. Position the patient on his back.
d. Use undiluted hydrogen peroxide as a cleaner.

Tonyam972 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
Understanding normal growth and development helps nurses predict, prevent, and detect deviations from patients' own expected patterns. The nurse can then compare expected patterns of activity based on age with the patient's stated activity patterns to determine deviations from the patient's own expected patterns. Asking the patient to describe his/her usual daily activities will provide the nurse with useful information about the patient's own expected patterns. How many hours are spent watching television or in front of a computer and how many times the patient exercises in a week are closed-ended questions. These questions would not provide the nurse with as much information about the patient's expected patterns when his/her stated patterns are compared with expected patterns for the patient's age group to detect delays.

Answer to Question 2

A
If the patient is unconscious or uncooperative, or is having difficulty keeping the mouth open, insert an oral airway. Insert it upside down, then turn the airway sideways and over the tongue to keep the teeth apart. Insert when the patient is relaxed. Do not use force. Never place fingers into the mouth of an unconscious or debilitated patient. The normal response of the patient is to bite down. Position the patient on his side or turn his head to allow for drainage. Placing the patient on his back could lead to aspiration. Hydrogen peroxide and sodium bicarbonate effectively remove debris but, if not diluted carefully, may cause superficial burns.