Quality Care and Evidence Based Practice

The nurse is categorizing victims of hypothermia as having mild, moderate, and severe hypothermia. Which assessment findings will help the nurse identify the clients with moderate hypothermia? Select all that apply.

Hypovolemia Respiratory acidosis Moderate hypothermia causes hypovolemia and metabolic and respiratory acidosis. Asystole may be present in severe hypothermia; in fact, metabolic rate, heart rate, and respirations are so slow in severe hypothermia that they may be difficult to detect. Lethargy is a characteristic of mild hypothermia. Reflexes are absent in severe hypothermia, and the pupils are fixed and dilated.

Which sensory function is difficult to assess in preschoolers?

Smell Smell functions are difficult to assess in preschoolers; this function can be assessed in children six years of age or older. Taste, vision, and touch can be assessed in a preschooler.

What is the function of the hospital incident commander in a mass casualty event?

Assuming leadership for implementing the emergency plan Assuming leadership for implementing the emergency plan is the function of the hospital incident commander in a mass casualty event. A medical command physician decides the number, acuity, and resource needs of clients. Evaluating each client to determine priorities for treatment is the role of the triage officer. The public information officer serves as a liaison between the healthcare facility and the media.

What is the similarity between the formal operations period and the preoperational period according to Piaget's theory?

Both periods explain egocentric thought of an individual. The preoperational period and formal operations period explain the egocentric thought. The preoperational period describes "egocentrism" in a child at the age of 2 to 7 years; the formal operations period explains the egocentric thought from 11 years of age to adulthood. During the formal operations period, an individual believes that his/her actions and appearance are constantly being scrutinized by an "imaginary audience," which is not seen during the preoperational period. The preoperational period, not the formal operations period, tells about "animism" where the child thinks that there is life in every inanimate object. The preoperational period marks the beginning of the cognitive development, whereas formal operations period marks the end of cognitive development.

A nurse is assisting a primary healthcare provider with insertion of a central venous access catheter. Which equipment will the nurse plan to have in the room to help prepare the skin? Select all that apply.

Mask Gown Checklist Sterile gloves The primary healthcare provider who inserts the vascular access device wears sterile gloves, gown, and mask. Anyone in the room during the procedure must also wear a mask. Use a checklist during insertion to make sure everything is done correctly. Chlorhexidine is used for skin disinfection, because it has the best outcomes for preventing infection; betadine is not used.

Who undertakes the responsibility of identifying the need for and calling of different specialty-trained providers to care for clients in a disaster?

Medical command physician The medical command physician focuses on determining the number, acuity, and medical resource needs available for the clients in a disaster event. They are responsible for identifying the need for and calling specialty-trained providers to care for clients in the hospital. The triage officer re-evaluates the acuity for appropriate disposition within the hospital best suited to meet the client's medical needs. The public information officer serves as a liaison between the healthcare facility and the media. The hospital incident commander's role is to take a global view of the entire situation and facilitate client movement through the system.

A school nurse is screening children for scoliosis. In what age group is it usually identified?

Preadolescence Preadolescence is the time when scoliosis is most likely to become evident because of the growth spurt that occurs at this time. Although scoliosis may occur at any age, idiopathic scoliosis, the most common type, tends to become evident during the preadolescent growth spurt.

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client?

Softening of nail beds and flat nails Softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing of the nails. Clubbing results in a change of the angle between the nail and nail base, and is seen in conditions of oxygen deficiency, such as in heart or pulmonary diseases. Conditions such as iron deficiency anemia and syphilis cause curvature of nails, which is called koilonychia. Transverse depressions in nails indicate a temporary disturbance of nail growth called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, and trichinosis. They are called splinter hemorrhages.