The nurse is contributing to a plan of care for a patient who has heart failure. What should be the major goal of nursing management for this patient?
a. Increase fluid intake.
b. Reduce the workload of the heart.
c. Increase venous return to the heart.
d. Promote a decrease in cardiac output.
ANS: B
Reducing the workload of the heart is the major goal for the patient with heart failure. A. Fluid overload is a manifestation of heart failure. C. Venous return needs to be promoted. D. A decrease in cardiac output would increase the patient's symptoms.
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After a nurse addresses an agitated client by setting limits in a calm, direct manner, the client begins pacing, exhibiting a clenched jaw and fists. The nurse would evaluate the approach as ineffective because:
1. The nurse lacks rapport with the client. 2. The nurse lacks adequate de-escalation and limit setting skills. 3. Some clients have limited control, so verbal interventions may not work, but this is not reflective of the nurse's skill. 4. In some cases verbal de-escalation and limit setting will not work and the nurse should start with a more restrictive measure.
A perinatal nurse is working with a woman who has had four perinatal losses in the first 20 weeks of pregnancy. The nurse should anticipate orders for which of the following diagnostic tests? (Select all that apply.)
A. Cervical cultures B. Hysterosalpingogram C. Maternal/paternal karyotype D. Sickle cell screening E. Thyroid-stimulating hormone (TSH) levels
Phantom pain is pain or other discomfort, such as burning, tingling, throbbing, or itching, in the missing limb
Indicate whether the statement is true or false
Acute pain:
a. Is felt suddenly b. Is felt in a body part that is no longer there c. Is felt at the site of tissue damage and in nearby areas d. Is constant or occurs on and off