Identify the most appropriate nursing diagnosis for promoting the safety of a frail, elderly patient after hip replacement surgery, who also has a history of emphysema
1) Impaired Mobility related to weakness
2) Ineffective Breathing Pattern related to disease process
3) Activity Intolerance related to injury
4) Risk for Injury related to medical condition
ANS: 4
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The nurse is performing an assessment of the client's peripheral vascular system. Which actions by the nurse are appropriate when assessing this client?
1. Assessing the client in a flat, supine position when the client exhibits a respiratory rate of 26 breaths/min. with a dusky appearance around the mouth and lips. 2. Requesting the client remove all undergarments prior to putting the gown. 3. Assessing pedal pulses over the client's socks. 4. Taking a blood pressure cuff, Doppler, and stethoscope into the client's room for the assessment.
The charge nurse is observing a newly licensed nurse conduct an abdominal assessment on a client admitted with an abdominal mass that is affecting bowel elimination. Which actions by the newly licensed nurse would require the charge nurse to intervene?
Select all that apply. A) Performing palpation before auscultation B) Performing auscultation before palpation C) Using inspection, auscultation, percussion, and palpation during the abdominal assessment of the client D) Using only inspection, percussion, and palpation during the abdominal assessment of the client E) Using deep palpation during the assessment process
A client with a chronic cough, wheezing, and a sore throat states these symptoms have been present for 3 months, and asthma is not the cause. What does the nurse suspect to be causing this client's respiratory issues and sore throat?
1. Zollinger-Ellison syndrome 2. Gastroesophageal reflex disease 3. Crohn disease 4. A gastric ulcer
The 65-year-old male who, although he is having painful symptoms related to a benign enlargement of the prostate, refuses to consider a prostatectomy because he fears that the surgery will make him impotent. The nurse reassures him that:
a. a prostatectomy will enhance sexual function. b. new techniques for a prostatectomy do not damage nerves. c. the prostate has nothing to do with erection or seminal fluid production. d. impotence following a prostatectomy is entirely psychological.