The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds did the nurse auscultate during the assessment?
1. Pleural rub
2. Hyperactive bowel sounds
3. Crackles
4. Bruit
4
The nurse may auscultate a bruit at the site of the aneurysm. Pleural rib and crackles are adventitious sounds heard during the assessment of the lungs. Hyperactive bowel sounds may be heard when assessing the abdomen.
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An ICU nurse has just assisted the physician in placing a central line in a client. Over the past few days the client's son has been increasingly verbally abusive to the nursing staff
The unit secretary tells the nurse that the son is at the nurse's station demanding to see the client. Which action by the nurse is most important? 1. Remove the central line tray from the room. 2. Inform the son regarding the client's condition. 3. Ignore the son as he enters the client's room. 4. Limit the son's visitation.
A nurse writes down the following outcome for a depressed patient: "By 6/9/12, the patient will state three positive benefits of receiving counseling." This is an example of which of the following types of outcomes?
A) psychomotor B) cognitive C) affective D) realistic
Which action would the nurse take when giving advice using the acronym FRAMES?
a. Offer a menu of options or choices. b. Provide clear guidance to change risky behavior. c. Support the client's ability to change the behavior. d. Emphasize the client's responsibility for change.
Oscar is a 67-year-old patient who experienced a myocardial infarction. He asks the nurse why his chest hurt when he had his heart attack. What is the best response from the nurse?
A. "One of your heart valves wasn't working properly and caused an obstructed blood flow." B. "One of your coronary arteries was blocked, and your heart muscle wasn't able to get enough blood." C. "Your heart muscle was deprived of oxygen, which caused chest pain." D. "The heart muscle is sensitive to changes in electrical conduction."