1. A nurse rates a clients bicep reflex as 2+. Which of the following characteristics should the nurse document about th

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1 A Nurse Rates A Clients Bicep Reflex As 2 Which Of The Following Characteristics Should The Nurse Document About Th 1 (59.55 KiB) Viewed 80 times

1. A nurse rates a clients bicep reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes? A. Diminished B. Average C. Brisk D. Hyperactive Rationale: 2. A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.) A. Document restraint checks and client status every 2 hr. B. Educate the client's family about restraint use. C. Obtain the provider's prescription renewal every 72 hr. D. Implement passive range-of-motion exercises. Rationale: 3. A nurse is providing breast self-examination teaching to a client who is menopausal. Which of the following statements should the nurse identify as an indication that the teaching was effective? (Select all that apply.) A. "I don't have to lie down to check my breasts. I can stand in the shower." B. "If I feel a firm ridge in the lower curve of my breasts I should report this immediately." C. "It is important to press firmly when feeling my breasts to detect changes." D. "Since I no longer have periods, I can perform an examination at any time of the month." E. "I will make sure to feel for changes in my underarm area." Rationale: 4. A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A. "Tilt your head slightly forward" B. "Keep your head straight and look ahead of you." C. “Tilt you head back and swallow" D. "Turn your head to the side and against my hand."