An 88-year-old client is admitted with an extracellular fluid volume excess. On admission, he is frightened and exhibiting dyspnea. On assessment, the nurse would expect to identify:
1. a weak, thready pulse.
2. poor or sluggish skin turgor.
3. neck vein distention.
4. postural hypotension.
ANS: 3
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Conflict is best handled by:
1. managing it. 2. avoidance behavior. 3. aggressive management. 4. passive management.
A father brings his infant to the community clinic and tells the pediatric nurse that his son has been experiencing bouts of diarrhea for the past 2 days
The nurse notes that the infant is diagnosed with malabsorption syndrome and suspects the infant has: A) osmotic diarrhea. B) secretory diarrhea. C) motility disorder diarrhea. D) inflammatory process diarrhea.
The nursing assistant reports that the hearing-impaired client is alert and oriented with the hearing aid in place but the client does not respond to verbal communication this morning. Which should the nurse implement first?
1. Document that the client's neurological status is poor. 2. Assess the client for clinical indicators of a stroke. 3. Remove the hearing aid and clean it with a stiff brush. 4. Instruct nursing assistant to check hearing aid battery.
MC When providing preoperative teaching for a client undergoing lithotripsy, which of the following instructions would not be appropriate to include in the teaching?
A. Pain medication is given as gravel is being passed following the procedure. B. Fluids are given in large quantities to hydrate the kidney following stone manipulation. C. Liver function studies are monitored following a gallstone procedure. D. Bed rest is maintained until gravel is passed.