Routine hygienic care has been provided to the client, with no abnormal findings assessed. Which item will the nurse document in the medical record?
1. Foot care
2. Hair care
3. Removal or insertion of a hearing aid
4. Type of bath provided and client's ability to provide self-care
Correct Answer: 4
The nurse would document what type of bath was provided to the client and the client's ability to assist or provide self-care. Foot care, hair care, and removal or insertion of a hearing aid usually is not documented unless there are unexpected assessment findings.
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A critically ill patient is admitted for "thyrotoxicosis." An appropriate nursing assessment would be
A) checking the patient's temperature. B) monitoring intake and output. C) performing daily weights. D) assessing for signs of infection.
An elderly patient is concerned that his stress level is affecting his ability to cope with many of his activities of daily living
He states that he was "raised in a family that didn't get along well" and has "struggled with his emotions in the past." The nurse's best response is: A) Family experience and early childhood experiences often have little influence on our coping ability, and stress is often related to needless worry. B) Coping is determined by our own attitude and how we decide to view our family life today; behavior needs to be controlled to decrease stress level. C) Family experience and early childhood experiences often influence a person's ability to cope, and exploring these issues may help relieve stress. D) Children raised in dysfunctional homes may become mentally ill later in life and need to be medicated; do you feel like medication may help?
The nurse is performing a pain assessment on a client who is unable to communicate verbally. Which vital sign data would indicate that the client is in acute pain? Select all that apply
1. Temperature of 100.6 degrees. 2. Pulse rate 94. 3. Respiratory rate 32. 4. Blood pressure 158/92 mmHg. 5. Facial grimacing.
When a patient is experiencing a panic attack, the nurse coaches the patient in:
a. reality orientation. b. decision making. c. rational thought. d. deep breathing.