It has been determined that each one of the following clients is at risk for falling. Which one requires the nurse's priority for ambulation?
a. A 16-year-old with a sprained ankle being discharged from the emergency de-partment
b. A 54-year-old who has taken the initial dose of an antihypertensive medication
c. A 45-year-old postoperative client up for the first time since knee surgery
d. An 81-year-old who is asthmatic and had a hip replaced 18 months ago
C
Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) com-promise the ability to remain balanced. Medications that cause dizziness and prolonged immobil-ity also affect balance. Although all of the options represent a potential risk for falling, the post-operative client has both prolonged immobility and physical injury (surgery) and so is at greatest risk.
The 16-year-old with a sprained ankle being discharged from the emergency department is not the priority for ambulation.
The 54-year-old who has taken the initial dose of an antihypertensive medication is not the prior-ity for ambulation.
The 81-year-old who is asthmatic and had a hip replaced 18 months ago is not the priority for ambulation.
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The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:
a. Check for the presence of exophthalmos. b. Suspect that the patient has hyperthyroidism. c. Ask the patient if he or she has a history of heart failure. d. Assess for blepharitis, which is often associated with periorbital edema.
During physical assessment of a patient who has frequent nosebleeds, the nurse finds nasal sores and necrosis of the nasal septum. The nurse should ask the patient specifically about the use of which drug?
a. Heroin b. Cocaine c. Tobacco d. Marijuana
The nurse manager is planning the holiday schedule for the staff on the Oncology unit. The staff is highly experienced, and has worked well together for more than five years. Which situational leadership model is best used in this situation?
1. Participating 2. Telling 3. Selling 4. Delegating
When would a nurse use The Guide to Clinical Preventive Services?
a. Conducting group risk appraisal and risk reduction b. Providing recommendations for preventive interventions c. Completing a community wellness inventory d. Improving environmental living conditions and sanitation