When assessing a client's abdomen, a nurse notes pain when depressing and releasing fingertip pressure in the right lower quadrant. How should this finding be documented?
a. "borborygmi present"
b. "rebound tenderness"
c. "separation of the rectus abdominis muscle in the RLQ"
d. "tympany present"
B
Rebound tenderness is noted when depressing and releasing fingertip pressure in the right lower quadrant. This may indicate possible inflammation of the appendix.
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Unlicensed assistive personnel (UAP) ask the nurse to explain the difference between cultural care and other types of care. What would the nurse say in response to the UAP?
A. It is holistic. B. It is a fad. C. It focuses on scientific theory. D. It is a belief system.
During a physical examination, a nurse responds to the patient's behavior and concerns. Which responses by the nurse are considered judgmental? Select all that apply
a. "You shouldn't feel that way." b. "Tell me more about your feelings." c. "That sounds like a very good point." d. "That is bad to say about yourself." e. "What made you come to that conclusion?" f. "What do you think the results of the test will be?"
When caring for a client with an aldosterone deficiency, the nurse should monitor the client for signs of?
A) hyperkalemia B) metabolic acidosis C) hypernatremia D) hypertension
Respite care may be needed when the:
a. primary carer is unwell. b. individual wishes to have a holiday. c. individual is unwell. d. individual has financial difficulties.