The nurse is caring for a 78-year-old woman who is brought to the emergency department from home. The client has a diagnosis of dementia and is being treated for abdominal pain
During the assessment, the nurse identifies multiple bruises on the extremities that appear to be 1 to 2 weeks old. The nurse also has resistance from the client during the insertion of a urinary catheter. The client's son is the caregiver and tells you the bruises are from the patient falling. The assessment of the physical injuries and the client's behavior indicate what intervention by the nurse?
A) obtain an order for disturbance in blood clotting
B) investigate for potential elder abuse
C) provide physical restraint to prevent the client from pulling out the catheter
D) sedate the patient to increase cooperation
B
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The nurse researcher is conducting a study on a nonpharmacologic nursing intervention for the treatment of pain. Which data collection instrument would provide the most sensitive measurement of pain?
1. Likert scale. 2. Physiologic measures. 3. Semantic differential. 4. Visual analog scale.
The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.)
a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output
The nurse is instructing a patient with a compromised immune status on the signs and symptoms of infections. What should be included in these instructions?
1. Increased sputum production 2. Cloudy urine 3. Irritated oral mucosa 4. Purulent wound drainage
When evaluating a client for an end point for therapy with an HMG-CoA reductase inhibitor, the nurse monitors to detect when:
a. serum cholesterol levels drop below 250. b. serum cholesterol levels drop below 200. c. transaminase levels rise and remain at 3 times the upper limit of normal. d. transaminase levels drop to less than one-half of the normal.