What is the recommendation for environmental safety when clients have poor judgment?
1. Use measures to decrease agitation.
2. Schedule ADLs at a regular time daily.
3. Turn the temperature down on the hot water heater.
4. Provide aids to assist with orientation.
3
Rationale: Turning the temperature down on the hot water heater will help to prevent accidental burns when bathing or washing dishes. Using therapeutic measures to decrease agitation is recommended for clients with high risk for other-directed violence. A routine daily schedule and orientation aids will structure the client's environment to promote optimal orientation.
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During a history examination, a patient tells the nurse, "The cardiologist says I have a leaking valve." The nurse documents that the patient has a history of
a. acute mitral regurgitation. c. chronic mitral regurgitation. b. aortic insufficiency. d. pericardial friction rub.
The nurse is applying an alcohol-based antiseptic rub to the hands after providing client care. What should the nurse do once the antiseptic has been applied?
a. Wash the hands with soap and water. b. Rinse the antiseptic off the skin. c. Allow the rub to dry. d. Wipe the antiseptic off the skin.
In which location of the chart would the nurse most likely chart hourly urinary output for a patient?
a. Kardex c. flow sheet b. care path d. critical pathway
The nurse assessing a child with known right-sided heart failure will expect to find which of the following symptoms?
1. Crackles in the lungs 2. Increased edema in the face 3. A galloping rhythm 4. All of the above are symptoms of right-sided heart failure.