Which of the following health history and physical assessment findings place an elderly client admitted for abdominal pain at risk for infection? (Select all that apply.)
1. Redness at the IV site
2. Productive yellow cough
3. Foley catheter placement
4. History of bipolar disorder
5. Oral temperature of 98.8° F
6. Recent radiation for prostate cancer
ANS: 1, 2, 3, 6
Learn to group significant findings into clusters of data that reveal actual or "risk for" nursing diagnoses. A history of bipolar disorder and an oral temperature of 98.8° F do not indicate the client is at risk for an infection.
You might also like to view...
The expression of spiritual or religious beliefs in many cultures include
1. fugues. 2. amnesia. 3. trances. 4. depersonalization episodes.
The prescriber has written an order for a muscarinic agonist. For which patient would a muscarinic agonist be indicated?
a. A patient with urinary retention b. A patient who suffers from intestinal obstruction c. A patient with a heart rate of 60/minute d. A patient who experiences orthostatic hypotension
A 65-year-old male with several risk factors for CAD is scheduled for exercise testing in 2 days. The clinic nurse calls the client at home to provide instruction prior to testing
Which of the following statements made by the client indicates a need for further teaching? 1. "I may have a cigarette or two just before the test because I'm very nervous about the results.". 2. "I won't eat for at least 3 hours prior to the test.". 3. "I will walk on a treadmill and my heart and blood pressure will be monitored.". 4. "I will check with the doctor to see if I should take my heart medications but will hold my metformin until after the test.".
Which of the following terms describes a standard and comprehensive way of collecting information about a patient to be used by various members of the healthcare team?
A. medical history B. vital signs C. laboratory test results D. diagnostic test results