A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores?
1. Trending can only be accurate if the same scale is used.
2. There is a definite trend of low risk for pressure ulcer development.
3. Trending would be more accurate if the same scale was used.
4. The scores indicate opposite risks for pressure ulcer development.
Correct Answer: 3
Rationale: All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used.
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During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a nursing diagnosis plan
What does this data represent? a. Symptoms b. Data clustering c. Signs of fluid overload d. Urinary retention
The nurse is providing care to a client with pneumonia is has a fever. Which interventions should the nurse use to attain the goal of normal body temperature?
Select all that apply. A) Increase the temperature of the room environment to prevent shivering. B) Administer antipyretic medications. C) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance. D) Use ice packs and a tepid bath every 2 hours. E) Promote frequent rest periods to increase energy reserve.
The nurse is preparing an educational seminar about Healthy People 2020
The inclusion of which of the following topics in this presentation are unexpected and indicate that the nurse requires further education? Standard Text: Select all that apply. 1. The parents of a newborn should be educated about the clinical manifestations associated with hyperthyroidism. 2. Thyroid disease more frequently affects males than females. 3. Immigrants may have an increased risk of disorders related to thyroid function. 4. Depression in older adults may be linked to hypothyroidism. 5. The iodine added to some medications can be linked to hypothyroidism in the clients who use these medications.
Priority nursing interventions for a client with borderline personality disorder who has a history of self-mutilation and is currently angry, irritable, and impulsive would be:
1. Establishing a contract for safety with the client 2. Teaching the client ways to manage anger 3. Helping the client tolerate feelings 4. Implementing behavioral modification