Answer to Question 1
A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting techniques. Consider individual patient problems during transfer.
Answer to Question 2
A
A. Assistive personnel can be trained to count apical pulse and peripheral pulses after the nurse's initial assessment. Assistive personnel need to be instructed to recognize temperature and color changes along with changes in peripheral pulses.
B and C. Comprehensive heart and neck vessel assessment should not be delegated to assistive personnel.
D. The order of an abdominal assessment differs from that of other assessments. The nurse begins with inspection and follows with auscultation. It is important to auscultate before palpation and percussion because these maneuvers may alter the frequency and character of bowel sounds. This skill should not be delegated to assistive personnel. However, assistive personnel should know to report the development of abdominal pain or changes in the client's bowel habits or dietary intake.
The liver in this photograph was from a deceased patient with an advanced state of cirrhosis.
Teaching an illterate patient
Patient teaching: nail assessment
A goniometer is used to measure range of motion of the patient’s arm.