The client's neck veins are full in the sitting position. What should the nurse do first in response to this observation?
A. Document the observation as the only action.
B. Measure urine specific gravity and volume.
C. Assess the pulse and blood pressure.
D. Assess deep tendon reflexes.
C
Neck veins in the normovolemic person are full in the supine position and flat in the sitting posi-tion. Full neck veins in the sitting position are an indicator of overhydration. Checking the pulse and blood pressure can help determine if overhydration is present.
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A female patient is seen for "increased hoarseness" and "a change in voice quality." What is an appropriate assessment question for the nurse to ask this patient?
1. "What medications are you currently taking?" 2. "Have you recently had a cold?" 3. "Have you recently visited another country?" 4. "What is your occupation?"
The nurse brings the client's medications into the room and the client shouts, "You don't care if I take these, so get out of my room!" Which response by the nurse is most likely to diminish the client's anger?
1. "Who misinformed you about my feelings?" 2. "You seem very angry about the medications.". 3. "We know each other; why are you saying this?" 4. "I cannot leave until you take these medications.".
"Behind" means
A) superior. B) anterior. C) posterior. D) inferior.