On the diagram provided, place an X where the nurse would assess the apical pulse in an adult. (Figure 29-14)
What will be an ideal response?
Correct Answer:
Rationale : The apical is at the apex of the heart. In an adult, this is located on the left side of the chest, about 8 cm (3 in) to the left of the sternum at the fifth intercostal space.
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An older individual is touring an assisted living facility with his family in order to find a place to live after the death of his spouse and issues with mobility. Which characteristic of the facility is most in need of modification?
A) The temperature of common areas is kept between 75°F and 77°F B) Aromatherapy is used in the facility to provide a pleasant scent environment C) Area rugs are placed in front of each sink in residents' washrooms to ensure warmth D) There is more tile than carpet throughout the facility and carpets are glued to the floor
A nurse assesses the lower extremities of an older adult and notes a small ulcer between the per-son's great toe and second toe
The ulcer has well-defined edges and there is no bleeding; however, there is a small amount of necrotic tissue present. This wound is most likely a(n): a. venous ulcer. b. arterial ulcer. c. pressure ulcer d. surgical wound.
Person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate?
a. Help the person use online video calls to provide interaction with others. b. Advise the person to accept the situation and use a companion. c. Ask the person to explain why the fear is so disabling. d. Teach the person to use positive self-talk techniques.
The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant?
A. A client scheduled for a liver biopsy B. An unconscious client who requires oral care C. A client who has just undergone cardiac catheterization D. A client who is getting up to ambulate for the first time after surgery