The nurse is preparing to perform a focused assessment for a patient complaining of shortness of breath. Which equipment will be needed?
a. Flashlight
b. Stethoscope
c. Tongue blades
d. Percussion hammer
ANS: B
A stethoscope is used to auscultate breath sounds. The other equipment may be used for a comprehensive assessment but will not be needed for a focused respiratory assessment.
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A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?" How should the nurse respond?
a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."
A patient is being treated for an aneurysmal subarachnoid hemorrhage (SAH) that occurred 10 days ago
The nurse recognizes that the patient is at risk for decreased cerebral blood flow and is especially concerned when which assessments are made? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient seems unable to verbalize needs. 2. The patient has difficulty starting the flow of urine. 3. The patient reports a stiff neck. 4. The patient has a temperature of 101°F. 5. The patient has unequal but reactive pupils.
Observation of the child playing in the playroom provides information about which two systems?
a. Dermatologic and cardiovascular b. Neurologic and musculoskeletal c. Respiratory and ear, nose, and throat d. Gastrointestinal and genitourinary
The nurse contacts the client's case manager to provide information about the client's hospital treatment plan. This is an example of which type of advocacy?
a. Role modeling b. Educational informing c. Collaboration d. Anticipatory guidance