You are helping care for your 89 year old grandmother who is sick with "the flu". Her temperature is 101.2. What other information would be most useful to better assess your grandmother's condition?
a. what her temperature was yesterday
b. how long she has felt sick
c. what her usual temperature is
d. how much she ate today
C
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A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse complete as part of the nurse's role? (Select all that apply.)
a. Maintain the safety of adaptive devices by monitoring their function and making repairs. b. Coordinate rehabilitation team activities to ensure implementation of the plan of care. c. Assist clients to identify support services and resources for the coordination of services. d. Counsel clients and family members on strategies to cope with disability. e. Support the client's choices by acting as an advocate for the client and family.
The nurse is admitting an adult client to the hospital who seems to be withdrawn. The nurse interprets this as a response to the admission, knowing that one of the most common responses to hospital admission is:
1. Fear of the unknown. 2. Crying. 3. Regression. 4. Anger.
The client is receiving warfarin therapy after a thrombotic stroke. Which of the following international normalized ratios (INR) indicates that anticoagulation is adequate?
A. Client's INR is 0.05 to 1.0. B. Client's INR is 2.0 to 3.0. C. Client's INR is 5 times the control value. D. Client's INR is the same as the control value.
A head circumference is being measured at a 4 month old's well-baby checkup. It is noted that the head circumference has not grown since the previous assessment. The nurse should:
1. Ask the mother about the child's nutrition. 2. Notify the doctor. 3. Re-measure the head circumference, check developmental milestones, assess the nutritional status, and discuss the findings with the doctor. 4. Document the normal findings.