Although restraint is prescribed by a health care provider, the restraint is a measure carried out by nursing staff. The nurse caring for the patient is responsible for safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the application of restraining devices and the care of the patient in restraint, but the nurse remains responsible for outcomes. Even when family agree to restraint, nurses are responsible for providing safe outcomes. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 31-25 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment
an ax
10. A new nurse asks, “My elderly patient’s CT scan of the head shows many Lewy bodies are
nd
_x
present. What should I do about assessing for pain?” Select the best response from the nurse manager. a. “Ask the patient’s family if they think the patient is experiencing pain.” b. “Use a visual analog scale to help the patient determine the presence and severity of pain.” c. “There are special scales for assessing patients with dementia. Let’s review how to use them.” d. “The perception of pain is diminished by this type of dementia. Focus your assessment on the patient’s mental status.”
_a
ANS: C
an
ks
Lewy bodies associated with dementia [Faculty note: Lewy bodies are defined and addressed in Chapter 23]. There are special scales to assess the presence and severity of pain in patients with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing, negative vocalizations, body language, and consolability. A patient with dementia would be unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths.
es
tb
PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 31-9, 10, 34 (Figure 31-4) | Page 31-37 (Box 31-2) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment 11. An advance directive gives legally binding direction for health care interventions when a
ay
:t
patient a. has a new diagnosis of cancer. b. is diagnosed with Parkinson’s disease. c. is unable to make decisions for self because of illness. d. diagnosed with amyotrophic lateral sclerosis is unable to speak.
eB
ANS: C
Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinson’s disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 31-14, 15 TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment
eBay: testbanks_and_xanax
