A client who underwent liver transplantation 2 weeks ago reports a temperature of 101° F (38.3° C) and right flank pain. Which is the nurse's best response?
a. "The anti-rejection drugs you are taking made you susceptible to infection."
b. "You should go to the hospital imme-diately to have your new liver checked out."
c. "You should take an additional dose of cyclosporine today."
d. "Take acetaminophen (Tylenol) every 4 hours until you feel better."
B
Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. The other statements are not appropriate.
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Which of the following situations best describes feedback?
1. The answers the patient gives to your questions. 2. The patient explains what another nurse taught him. 3. The doctor gives you an order and leaves the unit. 4. You recognize the patient does not speak English well, but you explain and hope for the best.
Explanation: 1. This supports a diagnosis of risk for ineffective protection. 2. Caregiver role strain is the priority since the son needs to help the older patient who is hard of hearing and has difficulty completing activities of daily living. The son may become stressed with having to help the older patient as well as himself with care needs. 3. This supports a diagnosis of situational low
self-esteem. 4. This supports a diagnosis of social isolation. 1. Indicators of abuse screen 2. AMA assessment protocol 3. Adult protective services report 4. Brief abuse screen for the elderly 5. Hwalek-Sengstock elder abuse screening test
A patient in good health and without any major health needs says, "I want to try some nutritional supplements I read about on the Internet." What information would be appropriate for the nurse to include in a response? Select all that apply
a. "Most healthy people who eat a balanced diet do not need nutritional supplements." b. "Research has not supported claims that various nutritional supplements create significant benefits in healthy people." c. "Some nutritional supplements are proven to significantly delay aging and reduce the incidence of age-related diseases like cancer." d. "I am glad you are actively engaged in managing your health by trusting information from the Internet." e. "Researchers are still studying the benefits and side effects of many supplements. We should know more in the years to come."
A previously toilet trained toddler has started wetting again. A nurse is gathering a health history from the grandparent. Which health history finding will the nurse most likely consider as the cause of the wetting?
a. Dietary changes b. Recent parental death c. Playmate moved away d. Sibling was sick 2 days