The nurse demonstrates the correct technique for assessing the psoas sign by which action?
A) Applying deep palpation pressure to the client's right lower quadrant, then suddenly releasing
B) Tapping fingerpads over the client's abdominal wall, feeling for a floating mass
C) Flexing the client's right hip and knee, rotating the hip internally and externally
D) Flexing the client's right hip, applying downward pressure on the right thigh
D
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At the completion of the physical assessment, you should discuss future plans and answer any questions the patient may have after
a. assisting the patient to a sitting position. b. documenting your findings. c. formulating a nursing care plan. d. providing adequate time for the patient to redress.
A notation on a client's health record notes that she has a subclinical infection. The nurse assessing this client would expect
a. clinical manifestations of the disease that are not as dramatic as usual. b. fever with no elevation in the white blood cell count. c. no systemic manifestations of disease. d. reports of fatigue and lassitude after the infection.
A patient tells the nurse that he has damaged cartilage in his knee. How should the nurse respond to this information?
1. "It will take a few months for the damage to heal." 2. "That is considered a strain and will heal itself in a few weeks." 3. "Exercise will increase the healing time for the cartilage." 4. "Did the doctor talk with you about treatment options?"
An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first?
a. Notify an elder protective services agency about the possible abuse. b. Make a referral for a home assessment visit by the home health nurse. c. Have the family member stay in the waiting area while the patient is assessed. d. Ask the patient how the injury occurred and observe the family member's reaction.