During a head-to-toe assessment, the nurse assesses the patient's perineal area. Which area should the nurse assess next?
a. Chest
b. Arms
c. Abdomen
d. Legs and feet
ANS: D
When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.
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A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea as a result of pulmonary venous hypertension. What valvular disorder would cause pulmonary venous hypertension?
A) Aortic regurgitation B) Mitral stenosis C) Mitral valve prolapse D) Aortic stenosis
Nurses in private duty positions faced several hardships, including (Select all that apply.)
a. a shortage of nurses as schools limited enrollment. b. a surplus of nurses starting in the mid-1920s. c. employment that was sporadic and seasonal. d. opportunities primarily working with poorer families. e. pay that continued to be lower than other jobs.
A client diagnosed with paranoid schizophrenia becomes agitated when asked to play a game. The client responds, "Do you want to be my girlfriend?" Which nursing response is most appropriate?
A. "You are upset now. It would be best if you go to your room until you feel better." B. "Remember, we have a professional relationship. Are you feeling uncomfortable?" C. "We have discussed this before. I am not allowed to date clients." D. "I think you should discuss your fantasies with your therapist."
The nurse is planning care for an 82-year-old obese female patient with Alzheimer's dementia. The patient wanders, is unsteady on her feet, and is visually impaired. What should the nurse give priority to when developing the plan of care?
a. Laboratory results b. Skin condition c. Safety d. Nutrition