Mrs. Falstaff, a 29-year-old mother of five children, is admitted to the hospital for abdominal pain. As a nurse admits Mrs. Falstaff, she asks a series of questions before performing a physical assessment
When asking Mrs. Falstaff about the history of her illness, Mr. Falstaff, who has accompanied his wife, answers all the nurse's questions. As the admission process progresses and the nurse gathers subjective data, the nurse requests that Mr. Falstaff allow his wife to answer the questions. The nurse does this because she believes that:
A. Mr. Falstaff is exhibiting abusive behavior.
B. Mr. Falstaff is being obnoxious.
C. Mrs. Falstaff is the best source of information.
D. Mr. Falstaff is too controlling of his wife.
C
A patient is usually the best source of information. A patient who is alert and answers questions appropriately provides the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living.
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A client recovering from a small bowel resection is experiencing gas and abdominal distention. The nurse should plan care for the client based on the knowledge that postoperative gas pain occurs as a result of:
1. inflammation of the bowel at the site of the anastomosis. 2. impaired peristalsis. 3. hyper-motility of the bowel. 4. nasogastric suctioning.
A patient and his family are excited that he is transferring from the critical care unit to the intermediate care unit. However, they are also fearful of the change in environment and nursing staff
To reduce relocation stress, the nurse can: (Select all that apply.) a. ask the nurses on the intermediate care unit to give the family a tour of the new unit. b. contact the intensivist to see if the patient can stay one additional day in the critical care unit so that he and his family can adjust better to the idea of a transfer. c. ensure that the patient will be located near the nurse's station in the new unit. d. invite the nurse who will be assuming the patient's care to meet with the patient and family in the critical care unit prior to transfer.
An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and back of the thighs
The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patient's burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred.
The most effective agent for antisepsis of intact skin prior to an invasive procedure such as IV insertion is:
1. iodine tincture. 2. an iodine solution. 3. povidone-iodine. 4. a Betadine scrub.