An older patient begins to cry when talking about the death of a daughter 20 years ago. Which response should the nurse make first?
1. Assess the patient for depression.
2. Touch the patient's arm and listen in silence.
3. Ask the patient to describe the details of the death.
4. Explain that crying is an effective means to express emotions.
2
Rationale: Assessing the patient for depression could give the patient the impression that the expression of feelings of grief is not normal or healthy.
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During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where will the nurse best palpate the PMI?
A) Left midclavicular line of the chest at the level of the nipple B) Left midclavicular line of the chest at the fifth intercostal space C) Midline between the xiphoid process and the left nipple D) Two to three centimeters to the left of the sternum
Complete this analogy. NANDA : clinical judgment :: NIC : _________________
a. patient outcomes b. nursing actions c. diagnosis d. symptoms
During the change-of-shift report, the nurse learns that an assigned client has a hemoglobin level of 8 g/dL. Based on this information, the nurse should plan to:
1. Keep the client on strict bedrest to restrict activity. 2. Encourage ambulation to prevent thrombophlebitis. 3. Space activities in order to conserve energy. 4. Prevent exposure to infectious diseases.
Which of these conditions belongs to the herpes virus group and lies dormant in tissues waiting to be reactivated in the immunocompromised client?
a. cryptosporidium enteritis c. Pneumocystis carinii pneumonia b. cytomegalovirus d. tuberculosis