The nurse completes a nutritional assessment with assigned clients. For which client is an unplanned change in weight the most significant and has the highest priority for nursing interventions?
a. The client weighed 111 and lost 5 pounds in the last month
b. The client weighed 200 pounds and lost 9 pounds in the last month
c. The client weighed 135 pounds and lost 14 pounds during the last 6 months
d. The client weighed 155 pounds and lost 14 pounds during the last 6 months
c. The client weighed 135 pounds and lost 14 pounds during the last 6 months
An unplanned weight loss for a client of 5% or more over the course of 1 month, or 10% or more over the course of 6 months, is significant and requires interventions. The client, who weighed 135 pounds and lost 14 pounds during the last 6 months, had a weight loss of 10.4%. This client's weight loss is significant and would require immediate intervention. The client, who weighed 155 pounds and lost 14 pounds over 6 months, had a weight loss of 9%. The client, who weighed 200 pounds and lost 9 pounds during the last month, had a weight loss of 4.5%. The client, who weighed 111 pounds and lost 5 pounds in the last month, had a weight loss of 4.5%.
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A parent wonders why his baby needs all the blood samples to test for different diseases. What response by the nurse is best?
A. "Many serious disorders can be found before they cause damage or death." B. "This is a hospital policy; if you want to opt out you need to sign a waiver." C. "We see a lot of these diseases in our community so we screen for them." D. "Your baby doesn't need the blood tests if you don't want them."
A nurse who works on a palliative care unit has developed a strong partnership with the 77-year-old wife of a client who has recently died of lung cancer. The woman has expressed her fears around being a widow to the nurse
How can the nurse best respond? A) "You will likely find that once you are remarried the grief will subside and you will move on.". B) "It's very normal to have these fears, but antidepressant medications can help immeasurably with this difficult transition.". C) "Though it might not feel like it now, many women eventually find joy in new friendships and freedom after the death of a spouse.". D) "It will be important, and healthy, for you to maintain roles and routines similar to before your spouse died.".
An unknown unconscious client with an elevated temperature is ordered intravenous penicillin. What is the best action for the nurse to take?
a. Administer the medication. b. Check the chart for allergies. c. Look for medical alert identification. d. Notify the nursing supervisor.
The nurse determines that the has client sustained no injury from self-administration of medications. This describes which part of the nursing process?
a. assessment c. evaluation b. implementation d. nursing diagnosis