A confused client who is wandering is at risk for injury. The nurse should orient the
client to her surroundings, escort the client to her room to promote sleep, & use a
bed alarm to alert the nurse to further wandering behavior.
Give this one a try later!
confused client- action
, Multiple hard pallets may indicate problems with constipation or inadequate fluid
intake. A tarry appearance or read streaks may indicate bleeding. Brown liquid may
indicate diarrhea or decal impaction.
Give this one a try later!
Assess Feces
Until the health care professional responds, the nurse should provide
nonpharmacological pain modalities. Guided imagery & coaching in slow rhythmic
breathing are methods that can be effective in moderate pain management.
Give this one a try later!
Pain Management
Kortkoff sounds describe blood pressure from the first sound, which is a clear,
rhythmic, tapping sound that corresponds with systolic blood pressure, to the 5th
sound which is a disappearance of all sound & corresponds with diastolic blood
pressure. If the 1st kortkoff sound is heard immediately after releasing the valve, it
means that the cuff was not inflated high enough & all the air should be released & the
cuff reflated to a higher level.
Give this one a try later!
Korotkoff sound-immediate
client to her surroundings, escort the client to her room to promote sleep, & use a
bed alarm to alert the nurse to further wandering behavior.
Give this one a try later!
confused client- action
, Multiple hard pallets may indicate problems with constipation or inadequate fluid
intake. A tarry appearance or read streaks may indicate bleeding. Brown liquid may
indicate diarrhea or decal impaction.
Give this one a try later!
Assess Feces
Until the health care professional responds, the nurse should provide
nonpharmacological pain modalities. Guided imagery & coaching in slow rhythmic
breathing are methods that can be effective in moderate pain management.
Give this one a try later!
Pain Management
Kortkoff sounds describe blood pressure from the first sound, which is a clear,
rhythmic, tapping sound that corresponds with systolic blood pressure, to the 5th
sound which is a disappearance of all sound & corresponds with diastolic blood
pressure. If the 1st kortkoff sound is heard immediately after releasing the valve, it
means that the cuff was not inflated high enough & all the air should be released & the
cuff reflated to a higher level.
Give this one a try later!
Korotkoff sound-immediate
