To assess a newly admitted adult client's perception of reality, the nurse asks the client about
A) Person, place, and time
B) Family history
C) Memory ability
D) Confusional state
Ans: A
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A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next?
a. Assess the 24-hour fluid balance. b. Assess the client's oral cavity. c. Prepare to hang a normal saline bolus. d. Turn up the infusion rate of the TPN.
The nurse has requested an order to place a patient on suicide watch. Which data noted in the health assessment led the nurse to this conclusion? (Select all that apply.)
a. Threats of killing oneself b. Chronic pain c. History of prior suicide attempt d. Loneliness e. Stable heart rhythm
To effectively plan care for Asian American clients, a nurse should be aware of which cultural factor?
1. Obesity and alcoholism are common problems. 2. Older people maintain positions of authority within the culture. 3. "Tai" and "chi" are the fundamental concepts of Asian health practices. 4. Asian Americans are likely to seek psychiatric help.
While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth?
a. Risk for infection related to release of meconium b. Risk for injury related to high-risk birth interventions, such as amino infusion c. Risk for aspiration related to retained secretions d. Risk for thermoregulation because of high-risk labor status