The nurse is preparing to document an age-related change in posture observed in an older patient. Which term will the nurse most likely use to describe this observation?
1. Scoliosis
2. Lordosis
3. Kyphosis
4. Sway back
3
Rationale: Scoliosis is an "s" shaped spinal curvature that is not an age-related change in posture.
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Which statement would indicate that a novice nurse understands the concept of autonomy?
1. "All patients should be given their due." 2. "We must always be honest with patients." 3. "Part of our profession is doing good things for others." 4. "After I provide information, I will respect my patient's right to make a decision."
A client, who is at risk for pneumonia, has been ordered influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?
A) "Getting the flu can complicate pneumonia." B) "Influenza vaccine will prevent typical pneumonias." C) "Influenza is the major cause of death in the United States." D) "Viruses, like influenza, are the most common cause of pneumonia."
The nurse delegates the unlicensed nursing assistant (UAP) to ambulate an older adult client. What information must the nurse communicate to the UAP when delegating this task?
a. "The client has skid-proof socks, so there is no need to use your gait belt." b. "Teach the client how to use her walker while you are ambulating up the hall." c. "Sit the client on the edge of the bed with legs dangling before ambulating." d. "Ask the client if she needs pain medica-tion before you walk her in the hall."
The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)
a. Tachypnea b. Oliguria c. Confusion d. Pale extremities e. Hypotension f. Thready pulse