The complete assessment is done when the client is admitted to the healthcare facility. Information that the LPN/LVN may be asked to collect includes:(Select all that apply) Standard Text: Select all that apply
1. Allergies
2. Level of ambulation
3. Nursing diagnoses
4. Head to toe assessment
5. Fall risk assessment
1,2,4,5
Rationale: Allergies are an important piece of data to be collected during the health history
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Adherence to the concept of confidentiality for the patient's medical record requires that the nurse:
a. provide information only to another nurse. b. provide information only to an attorney. c. share information only with the family. d. have a clinical reason for reading the record.
An older client is experiencing increased itching and asks why this is occurring. What should the nurse explain to the client?
1. Cells shrink by losing fluid with aging. 2. Increased thirst causes the problem. 3. Reduced efficiency of the kidneys causes uremia. 4. Decreased respiratory compliance causes pruritus.
To perform the Romberg test, you should ask the patient to stand erect with the feet
a. together, and arms at the sides, first with the eyes open and then closed. b. slightly apart, arms straight out in front, and eyes closed. c. wide apart, arms at the sides, and eyes closed. d. together, arms elevated over the head, and eyes open.
The nurse observes that a patient being monitored with a pulmonary artery catheter has a missing c wave. Which of the following does this finding suggest?
1. It is difficult to determine the pulmonary artery occlusion pressure. 2. Nothing, because this wave is often missing from view. 3. It should appear at the end of the QRS complex. 4. It should appear simultaneously with the T-P interval of the ECG.