While assessing an older adult, the nurse anticipates that the client will respond slowly:
A) In order to be sure the correct answer is given.
B) Due to irreversible memory impairment.
C) Due to decreasing oxygen available to the brain secondary to decreased exercise levels.
D) In order to weigh the pros and cons of the perceived risk inherent in answering the question.
A
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A diet high in trans-fatty acids and saturated fat content is associated most often with which disease or condition?
a. obesity c. cardiovascular dis-ease b. diabetes d. cancer
A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a pa-tient. The RN will need to intervene immediately if the student nurse
a. presses on the skin over the tibia for 10 seconds to check for edema. b. palpates both carotid arteries simultane-ously to compare pulse quality. c. documents a murmur heard along the right sternal border as a pulmonic murmur. d. places the patient in the left lateral posi-tion to check for the point of maximal impulse.
A nurse notes that an older adult is unable to process complex thoughts and has difficulty forming sentences. Which of the following actions by the nurse is priority?
A) Review medication administration record. B) Place the client on high fall risk precaution. C) Assess muscle strength and deep tendon reflexes. D) Orient the client to environment.
The nurse is assessing the skin of a client being admitted to the long-term care facility from an acute care facility. A small blister is noted on the client's right heel. This is documented as
1. A stage I decubitus ulcer 2. A stage II decubitus ulcer 3. A stage III decubitus ulcer 4. A stage IV decubitus ulcer