You are caring for a male patient who has not spoken to answer any of your questions, but will nod or shake his head. He appears to have a developmental disability. Which of the following is the best way to document this information on your patient care report?
A) Patient refuses to answer questions.
B) Patient is non-verbal, but will nod his head yes and no.
C) Patient is developmentally disabled and unable to speak.
D) Patient is not responsive to questioning.
Question 2
Medical command has asked that you obtain orthostatic vital signs for a 54-year-old female complaining of dizziness and weakness. Her baseline vitals obtained while she was sitting in a chair were: pulse 84, respirations 26, blood pressure 118/62 mmHg, and SpO2 95. Which one of the following would indicate that the patient has a positive orthostatic test?
A) Supine blood pressure of 100/64 mmHg and respirations of 22
B) Standing blood pressure of 92/54 and heart rate of 106
C) Standing pulse of 88 with the additional complaint of nausea
D) Standing SpO2 88 and heart rate of 96 beats per minute
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Nurses possess a wide variety of experiences which they take into each patient encounter.
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