When evaluating the hydration status, the nurse observes tenting of the skin on the back of the 87-year-old client's hand when testing the skin turgor. What is the nurse's best action?
A. Notify the physician.
B. Examine dependent body areas.
C. Assess turgor on the client's forehead.
D. Document the finding as the only action.
C
Skin turgor and hydration status cannot be accurately assessed on an older adult client's hands due to age-related loss of tissue elasticity in this area. Areas that more accurately show skin tur-gor status on an older client include the skin of the forehead, chest, and abdomen.
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A woman calls the nurse at the mental health clinic about her husband who takes phenelzine (Nardil). She states that he took several over-the-counter decongestants and now has a stiff neck, headache, nausea, and vomiting
The nurse bases her response on what information? 1. Agranulocytosis is an adverse reaction that occurs due to the interaction of MAOIs and decongestants. 2. MAOIs can trigger a hypertensive crisis if taken with sympathomimetics. 3. Flu-like symptoms are common when clients begin taking MAOIs. 4. Neuroleptic malignant syndrome presents with muscular rigidity following the ingestion of MAOIs.
The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best position for this patient?
a. Flat on her back with knees flexed to help prevent hemorrhage b. On her side to prevent supine hypotension c. In the semi-Fowler's position to prevent supine hypotension d. In the knee-chest position to reduce pressure on the placenta
The client diagnosed with diabetes mellitus develops diabetic ketoacidosis after a religious fast. The client tells the nurse, "I have fasted during this season every year since I became an adult. I am not going to stop now."
The nurse is not knowledgeable about this particular religion. What is the best action for this nurse? 1. Tell the client that it is different now because of the diabetes. 2. Do some research into the meaning of fasting in this religion. 3. Ask family members of the same religion to discuss fasting with the client. 4. Request a consult from a diabetes educator.
Universally undesirable leadership behaviors include all of the following except
a. Asocial b. Loner c. Explicit d. Dictatorial