The nurse is assessing an older adult client in a long-term care facility after a fall. Which finding requires priority action?
A) The injured leg is shortened and externally rotated.
B) Redness and severe swelling are found at the hip joint.
C) Pain is relieved by moving the affected extremity.
D) The patient is repeatedly flexing the injured leg at the hip.
Answer: A
The client with a fractured hip is often in extreme pain and assumes a position with the leg on the affected side shortened and externally rotated because of gravity and the pull of the muscles. Any movement of the leg on the side of the affected hip is likely to cause severe muscle spasms and further pain. Redness and swelling are the classic signs of inflammation not immediately present after hip fracture. Extreme pain associated with hip fracture prevents any voluntary movement in the leg.
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The nurse is admitting a Native American patient with uncontrolled hypertension and type 1 diabetes to the unit
During the initial assessment, the patient informs the nurse that he has been seeking assistance and care from the shaman in his community. The nurse recognizes that the patient's blood pressure and his blood sugar level are elevated upon admission. What is the nurse's best response to the patient's indication that his care provider is a shaman? A) "Thank you for providing the information about the shaman, but we will keep that information and approach separate from your current hospitalization." B) "It seems that the care provided by your shaman is not adequately managing your hypertension and diabetes, so we will try researched medical approaches." C) "Don't worry about insulting your shaman, as he will understand his approach to your hypertension and diabetes was not working after your doctor tells him how sick you were in the hospital." D) "I understand that you value the care provided by the shaman, but we would like you to consider medications and dietary changes that may lower your blood pressure and blood sugar levels."
An older adult with dementia describes a pencil as "that thing that writes" and a water faucet as "the thing you turn." The nurse documents which problem?
a. Echolalia b. Apraxia c. Agnosia d. Amnesia
If an organization takes donations, this money is considered a:
a. profit. c. dashboard. b. revenue. d. variance.
Which of the following is a nursing consideration for a patient with a urinary tract infection (UTI) taking phenazopyridine (Pyridium)?
A. it may take 2 to 4 weeks before a response is seen B. phenazopyridine should be taken with a glass of milk or an antacid C. urine may turn orange or red D. the patient will need to take a potassium supplement while on phenazopyridine therapy