The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority for this patient?
a. "Do you have a headache or any dizziness?"
b. "Do you have any chest pain or shortness of breath?"
c. "When did you first notice the swelling and redness in your leg?"
d. "Do you have any cramping or muscle spasms in your leg?"
ANS: B
The highest risk of a DVT is the potential for the clot to break free and travel through the bloodstream to cause a pulmonary embolus (PE). The nurse should ask the patient about chest pain or shortness of breath to assess if a PE may have occurred.
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The charge nurse is reviewing the care plans for the clients on the unit. In several care plans, the nurse has noted that the words noncompliant and manipulative have been used to describe those clients with severe mental illness
The nurse plans on discussing this with the staff at the next unit meeting. Which of the following responses will demonstrate the charge nurse's personal accountability to the staff? 1. "If you use these terms regularly, you will need to reassess your reasons for working in psychiatric settings." 2. "Does the use of these terms reflect an underlying level of stress on the unit that I should be aware of?" 3. "While these terms might be accurate, they are not appropriate to use in a care plan." 4. "How might these terms reflect negativity and stigma towards persons with mental illness?"
Which nursing theorists promoted the interpersonal theory between the nurse and the patient?
A. Hildegard Peplau B. Hattie Bessent C. Mary Mahoney D. Linda Richards
Several of the life-supporting systems of the body are involved in shock. However, shock itself results from failure of the:
1. circulatory system. 2. endocrine system. 3. neurological system. 4. respiratory system.
As you approach a person who suffers from memory loss, the person becomes more anxious around 4 pm. The person appears to be extremely tired and afraid. What behavior is the person displaying? What will you do to help the person?
What will be an ideal response?