During a physical assessment, the nurse notes a patient passes frequent loose liquid stools. What should the nurse document that the patient is experiencing?
a. Dyspnea
b. Cyanosis
c. Diaphoresis
d. Diarrhea
ANS: D
Diarrhea is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools can mean there is bleeding in the intestines. Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.
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The instruction that is most helpful in teaching the rehabilitating CVA patient and his family about altered sensation is to:
1. make frequent assessments for signs of pressure or injury. 2. use the affected side in supporting the patient in ambulation and transfer to stim-ulate better sensation. 3. apply ice packs to the affected limbs to encourage return of sensation. 4. apply a heating pad to the affected limbs to increase circulation.
A patient is scheduled to have a vaginal examination and a Pap smear. Which patient statement indicates understanding of the nurse's instruction concerning the test and preparation?
1. "I cannot bathe for 36 hours prior to the examination." 2. "I should not douche the day before my exam." 3. "My period will not be a reason to defer my vaginal examination." 4. "My physician will use Vaseline to lubricate the speculum and prevent discomfort."
Which of the following is a good subjective question to ask a client with delirium?
a. "What is the date?" c. "Are you feeling restless or agitated?" b. "Where are we now?" d. ""What is the time?"
An orderly process that considers ethical principles, client values, and professional obligations is
a. Accountability b. Ethical decision making c. Moral principles d. Code for Nursing Practice