During an assessment for abdominal pain, a client reports a colicky abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to confirm the suspicion of cholelithiasis?
a. "Have you noticed any swelling in your ankles or feet at the end of the day?"
b. "Have you noticed a change in the color of your urine or stools?"
c. "Have you vomited up any blood in the last 24 hours?"
d. "Have you experienced fever, chills, or sweating?
ANS: B
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A 22-year-old man has come to a Veterans Administration clinic following a tour of duty in Iraq. He complains of uncontrollable anger and states that he "hates himself and is depressed because of a recent arrest for a fight in a tavern."
The nurse suspects the man will be diagnosed with: A) Situational depression B) Posttraumatic stress disorder C) Schizophrenia D) Acute depression
Which of the following statements accurately describe the impact on nursing of using NIC/NOC standardized languages? Select all that apply
A) They demonstrate the impact that nurses have on the system of healthcare delivery. B) They standardize and define the knowledge base for nursing curricula and practice. C) They limit the number of appropriate nursing intervention to be selected. D) They hinder the teaching of clinical decision making to novice nurses. E) They enable researchers to examine the effectiveness and cost of nursing care. F) They slow the development and use of nursing information systems.
A client receiving total parenteral nutrition (TPN) through a central line reports chest discomfort and mild dyspnea. The nurse notes a churning sound over the permanent pacemaker implantation (PMI) and tachycardia
Which action should the nurse take first? a. Replace the tubing and the TPN solution immediately. b. Clamp the central catheter and place the client on the left side with the head lower than the body. c. Start oxygen by mask to reduce the hy-poxia and notify the primary health-care provider immediately. d. Assess the client for cough and cyanosis while evaluating the central catheter site for signs of infection.
Explain and give examples for the four Is of transformational leadership. Must all four factors be present for someone to be transformational?
What will be an ideal response?