The nurse is caring for a patient who has had major abdominal surgery. She is concerned about the possibility of dehiscence. During her assessment, she makes sure she assesses for which of the following contributing factors? (Select all that apply
) a. Age
b. Malnutrition/obesity
c. Gender
d. Use of steroids
B, D
Factors that contribute to surgical wound dehiscence include anemia, malnutrition, obesity, and use of steroids.
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Which mental status assessment tool(s) would be appropriate for use in long-term care facilities? (Select all that apply.)
a. Fulmer SPICES b. Clock Drawing Test c. The Mini-Cog d. Mini-Mental State Examination (MMSE)
A patient with interstitial cystitis has just begun to take pentosan polysulfate sodium (Elmiron). The nurse would notify the physician if the patient exhibited which symptom(s). (Select all that apply.)
A) Petechiae B) Anorexia C) Decreased blood pressure D) Blood in the urine E) Headache
A client was admitted to the mental health unit after arguing with co-workers and threatening to kill
them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, two nursing diagnoses the nurse should consider are a. disturbed thought processes and risk for other-directed violence. b. spiritual distress and social isolation. c. risk for loneliness and deficient knowledge. d. disturbed personal identity and noncompliance.
The nurse is to ambulate a client who has an IV in her arm, an indwelling urinary catheter, and a chest tube. What action is appropriate for the nurse to take?
a. Hold the IV so it is higher than the client's heart while ambulating. b. Empty the urinary drainage bag before ambulating. c. Empty the closed chest drainage system before ambulating. d. Hold the closed chest drainage system above the client's chest level while ambulating.