After completing an integumentary status assessment, the nurse documents "+1 edema right lower leg." What does this documentation indicate?
A. Deep pitting, no obvious distortion
B. Pitting is obvious, extremities are swollen
C. Slight pitting, no obvious distortion
D. Pitting remains with obvious distortion
Answer: C
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The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia?
a. Global b. Broca's c. Dysphonic d. Wernicke's
Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside a hospital setting?
a. Automatic external defibrillator b. Carbon dioxide detector c. Pocket mask d. Transcutaneous pacemaker
When teaching a client how to cough productively, the nurse should instruct the client to:
a. drink plenty of fluids. b. take an OTC (over-the-counter) cough expectorant. c. cough from the diaphragm. d. sit forward to clear the throat of phlegm.
Discharge planning requires all of the following except
a. assessing the patient's plan of care to determine whether the outcome criteria are met. b. evaluation of whether the patient and family can continue with the necessary interventions or whether they need assistance. c. obtaining specific orders from the physician to begin the process of discharge planning. d. assessing the level of the patient's understanding with regard to his or her illness state and treatment regimen.