The nurse is admitting an older patient who requires a cane for ambulation, bilateral hearing aids, and monthly vitamin B12 injections. The daughter of the patient tells the nurse that the patient no longer remembers how to use a toothbrush or turn on the television set. Which information requires further assessment?
1. Vitamin deficiency
2. Loss of hearing
3. Assistive device for ambulation
4. Cognitive change
4. Cognitive change
Explanation: 1. Vitamin deficiency is being currently treated with medication and does not require further, immediate assessment.
2. Hearing loss is compensated with hearing aid devices and does not require further, immediate assessment.
3. Using a cane for ambulation compensates for unstable ambulation and does not require further, immediate assessment.
4. Normal, healthy older persons who forget what an item is used for or how to use it should be referred for further evaluation and treatment.
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The nurse observes a thick, tannish-brown covering over a large wound and needs to stage the wound. What action by the nurse is most appropriate?
a. Removing this covering with a sterile forceps and scissors b. Filling the base of the patient's ulcer with a silicone lotion c. Placing a hydrocolloid dressing directly over the tannish-brown covering d. Deferring staging until the tannish-brown covering has been removed
Which of the following is a suggested reason for the theory-practice gap in nursing?
A) There are two types of nurses - those who "practice" and those who "teach" B) Use of theory is limited due to current standards C) Theory supports current practice and protocol D) Publication of research in clinical journals
Because of rising health care costs, many hospitals are developing disease management programs. An interdisciplinary approach is used in staffing these programs. This represents what type of staffing system?
a. Case method b. Team nursing c. Case management d. Primary nursing
The nurse caring for a client experiencing back pain, nausea, and fatigue inquiries about current stressors. The client states, "I am sick. Why are you asking me about all of this stress stuff?" Which information should the nurse provide the client?
A. "Your nausea and fatigue are most often related to increase of stress in life." B. "I am assessing your ability to cope with additional stressors." C. "Screening for stress is required for every client." D. "Stress can impact our body by producing a variety of symptoms."