The nurse is admitting an elderly patient who uses two canes to ambulate. Which of the following tools should the nurse use when assessing this patient?
1. Braden Scale
2. Geriatric Depression Scale
3. Confusion Assessment Method
4. Morse Fall Scale
4
Rationale: The nurse should conduct a fall risk assessment. Since the patient has walking aids, the assessment tool that would provide the most information would be the Morse Fall Scale. This tool assesses for the risk factors of history of falling, multiple conditions, mental status changes, need for a walking aid or walking problems, and presence of IV therapy. The Braden Scale is used to determine the risk for skin breakdown. There is no evidence to suggest this patient is depressed or confused so those assessment tools would not be indicated at this time.
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Which one of the following statements regarding postoperative nutrition is correct?
A. Clients may have water on awakening from major surgical procedures. B. Clear liquid diets are provided for 2—3 days following minor surgical procedures. C. Soft diets are initiated the first postoperative day for major surgical conditions. D. Clear liquids are started after bowel sounds have returned for major surgical procedures.
3.27 + 0.08 = _____
a. 3.21 b. 3.35 c. 4.62 d. 1.8l
While administering vancomycin IV to a patient, the nurse suspects that the patient is developing red-man syndrome based on assessment of which of the following? Select all that apply
A) Headache B) Throbbing neck pain C) Chills D) Erythema of the neck and back E) Difficulty breathing
The nurse recognizes that the manifestations of Addison's disease are primarily related to the pathophysiology of
a. adrenal insufficiency. b. increased intracranial pressure. c. renal disease. d. thyroid hyperfunction.