The nurse has designed a treatment plan that includes the use of massage. Which intervention will the nurse implement first?
a. Assess the client to determine the most effective type of massage technique to use.
b. Inspect the skin over the tissue to be mas-saged to ensure that it is not infected or bruised.
c. Determine whether a licensed therapist will be needed to carry out the massage technique
d. Obtain permission from the client to im-plement this type of technique.
D
Permission to use the procedure must be obtained from the client before any of the other inter-ventions can be implemented.
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Standardized nursing terminologies such as the North American Nursing Diagnosis Association-International (NANDA-I) nursing diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) may be used in
the documentation process. Use of standardized language: (Select all that apply.) a. provides consistency. b. improves communication among nurses while excluding non-nurses. c. increases the visibility of nursing interventions. d. enhances data collection. e. supports adherence to care standards.
A patient reports chest pain. The nurse is attempting to assess the pain to differentiate the pain as cardiac, respiratory, or gastrointestinal
The nurse can properly identify the pain as cardiac in origin when the patient states that the cardiac pain: a. does not occur with respiratory variations. b. is peripheral and may radiate to the sca-pular areas. c. is aggravated by inspiratory movements. d. is nonradiating and occurs during inspira-tion.
The nurse performing an admission assessment of a 36-year-old client with cardiac valve disease would know the most relevant fact is that the client has
a. a childhood history of rheumatic fever. b. a recent rash on the upper extremities. c. allergies to shellfish. d. been a smoker for the last 3 years.
A nurse reads a complete blood count report for a patient who has been admitted to the hospital with fluid overload from late-stage kidney disease. What abnormal result would the nurse expect to find?
A) increased white blood cells C) decreased hematocrit B) increased platelets D) increased hematocrit