The nurse is performing an admission assessment on an 80-year-old patient who has frequent hospital admissions. The patient appears more disoriented and confused than usual. Which action by the nurse is correct?
a. Asking about medication doses
b. Asking for a neurologist consult
c. Requesting orders for liver function tests
d. Suspecting impaired renal function
ANS: A
An initial sign of drug toxicity in elderly patients may be confusion or changes in behavior. The nurse should ask about drug doses and notify the provider of the behaviors. The provider may order further evaluation based on examination of the patient.
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Which cardiovascular findings indicate to the nurse that the condition of the dying client is worsening?
A) Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles B) Pulse 72 beats/minute, irregular; patient confused and agitated C) Pulse 100 beats/minute, blood pressure 100/60 mm Hg, pale with poor skin turgor D) Pulse 60 beats/minute, blood pressure 90/42 mm Hg, difficult to arouse
While caring for a client with a newly placed plaster leg cast, a nurse should do which of the following? Select all that apply
1. Assess the toes for capillary refill. 2. Elevate the casted limb on pillows. 3. Handle the cast with the palms of the hand. 4. Lift the cast by gripping the ankle. 5. Teach the patient to use a nail file to scratch under the cast.
The purpose for a nurse periodically performing the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has schizophrenia is early detection of
A. acute dystonia. B. tardive dyskinesia. C. cholestatic jaundice. D. pseudoparkinsonism.
Categorizing a list of foods into food groups is an example of which level of Hierarchy of Cognitive Needs or Bloom's Taxonomy?
a. knowledge b. comprehension c. analysis d. application