The nurse is preparing to perform a rapid assessment. Which should the nurse plan on including in the assessment? Select all that apply.
A. General appearance.
B. Client identification.
C. Speech for clarity.
D. Facial expression.
E. Vital signs.
Answer: D
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During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate?
a. "The best time to examine your breasts is during ovulation." b. "Examine your breasts every month on the same day of the month." c. "Examine your breasts shortly after your menstrual period each month." d. "The best time to examine your breasts is immediately before menstruation."
A patient has a newly diagnosed heart murmur. During the nurse's subsequent health education, he asks if he can listen to it. What would be the nurse's best response?
A) "Listening to the body is called auscultation. It is done with the diaphragm, and it requires a trained ear to hear a murmur." B) "Listening is called palpation, and I would be glad to help you to palpate your murmur." C) "Heart murmurs are pathologic and may require surgery. If you would like to listen to your murmur, I can provide you with instruction." D) "If you would like to listen to your murmur, I'd be glad to help you and to show you how to use a stethoscope."
Why would this situation be potentially unsafe for the patient?
You receive a patient into the PACU and as the anaesthetist is handing over to you, you realise that you do not know what the surgery entailed or what the possible complications of that surgery might be. What will be an ideal response?
The nurse enters a patient's room and the patient startles easily and appears to jerk his arms and legs before awakening. Which stage of non-rapid eye movement sleep did the patient most likely awaken from?
a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4