What assessment data obtained by the home care nurse suggest that the client with heart failure has poor tissue perfusion?
A. The client has a right carotid bruit.
B. The client has a dry, hacking cough.
C. The client has a positive Allen's test.
D. The client has dyspnea while performing activities of daily living (ADLs).
D
Indications of poor tissue perfusion are activity intolerance, particularly with normal activities, fatigue, changes in mental status, and pallor or cyanosis.
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A child is admitted to the hospital unit with a diagnosis of Kawasaki disease. The physician writes the following orders. Which order would the nurse question?
1. Contact isolation 2. Oral aspirin (dose appropriate for weight) every eight hours 3. Echocardiogram 4. Vital signs every four hours
The nurse is using a stethoscope to assess a patient's cardiac status. This assessment technique is known as:
a. inspection. b. percussion. c. palpation. d. auscultation.
What instructions should be included in the discharge instructions for a 47-year-old patient with hypothyroidism?
a. Taking medication whenever symptoms cause discomfort b. Decreasing fluid and fiber intake c. Consuming foods rich in iron d. Seeing the physician regularly for follow-up care
An 80-year-old patient is brought to the clinic by her son. The son asks the nurse why his mother has gotten so many "spots" on her skin. What would be an appropriate response by the nurse?
A) "As people age, they normally develop uneven pigmentation in their skin." B) "These 'spots' are called 'liver spots' or 'age spots.'" C) "Older skin is more apt to break down and tear, causing sores." D) "These are usually the result of nutritional deficits earlier in life."