What activity will the nurse perform when assessing a client's fecal elimination status?
1. Obtain a nursing history
2. Interpret results of diagnostic tests
3. Perform a physical examination
4. Goal setting with the client
Correct Answer: 1
Rationale 1: Assessment of fecal elimination includes a nursing history and also a review of any data from the client's records.
Rationale 2: Interpretation of diagnostic test results would demonstrate evaluation of the nursing process.
Rationale 3: Performing a physical examination would demonstrate implementation of the nursing process.
Rationale 4: Setting goals for the client demonstrates the planning step of the nursing process.
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The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to:
a. Yield a falsely low blood pressure. b. Yield a falsely high blood pressure. c. Be the same, regardless of cuff size. d. Vary as a result of the technique of the person performing the assessment.
The nurse is instructing a patient, recovering from thoracic surgery, on pulmonary hygiene. Which of the following will facilitate the removal of lung secretions causing the least amount of pain to the patient?
1. Instruct the patient to cough 3 to 4 times with each exhalation. 2. Assist the patient to a sitting position to lean over the bedside table while coughing. 3. Provide the patient with a pillow to splint the incision while coughing. 4. Guide the patient to cough with the glottis open.
The developmental theory that is based on the process of socialisation is by:
a. Erikson. b. Piaget. c. Freud. d. Sigelman.
What is the primary factor that distinguishes a professional nurse's care from care provided by ancillary nursing staff?
a. Critical thinking b. Years of education c. Professional licensure d. Complexity of the task