The nurse is assessing a patient and notes dullness to percussion in the lowest point of the abdomen. When rolling the patient to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by
A) CHF and pyelonephritis
B) Cirrhosis and nephrosis
C) Metastatic neoplasms and CAD
D) CHF and CAD
B
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The nurse is caring for a client who has pulled out his IV twice. The nurse has replaced the IV in the left hand, and the physician has ordered restraints for the client
Which of the following restraints would meet the legal restraint requirements for this client? 1. A leather restraint on the right hand 2. Soft four-point restraints 3. A jacket restraint 4. An elbow restraint on the right arm
An elderly man drove from his home to a nearby convenience store and was unable to remember
how to get home. He was unable to tell a police officer his address and demonstrated labile mood, seeming pleasant one minute and angry the next. The officer took the individual to his home to discuss his condition with the family. The wife related that her husband often wanders around the neighborhood, sometimes taking tools from people's garages. She reluctantly agreed that he should go to the emergency department for evaluation. He was diagnosed with Alzheimer's disease. On the basis of the client's history, the nurse can make the assessment that the client's Alzheimer's disease has progressed to a. Stage 1 (mild). b. Stage 2 (moderate). c. Stage 3 (moderate to severe). d. Stage 4 (late).
A nurse is in the process of discharging an older client with an open abdominal wound requiring dressing changes. The nurse has instructed the client about the importance of maintaining adequate hydration
Which statement by the client shows the need for further instruction? A) "I can add an extra cup of decaffeinated coffee with breakfast and dinner." B) "I'll drink water and nonsugared beverages whenever I feel thirsty." C) "I will set up a schedule to drink a glass of water every 2 hours throughout the day." D) "If I drink a lot of fluids, I'll have to go to the bathroom more often, but I'll get more exercise."
What position should the patient assume before the nurse inserts an indwelling urinary catheter?
1) Modified Trendelenburg 2) Prone 3) Dorsal recumbent 4) Semi-Fowler's