A nurse determines that vital signs will need to be repeated within 4 hours in which of the following examples of recorded patient vital signs? Select all that apply
1. Blood pressure (BP) 164/90, temperature (T) 98.4°F, pulse rate (P) 89 bounding and regular, respiration rate (R) 26
2. BP 116/72, T 100.6°F, P 88 strong and regular, R 32
3. BP 110/74, T 97.8°F, P 74 strong and regular, R 19
4. BP 128/68, T 98.6°F, P 80 strong and regular, R 20
5. BP 112/86, T 97.8°F, P 48 weak and irregular, R 24
ANS: 1, 2, 5
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A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this group's teaching? (Select all that apply.)
a. "Rotavirus is more common among infants and younger children." b. "Escherichia coli diarrhea is transmitted by contact with infected animals." c. "To prevent E. coli infection, don't drink water when swimming." d. "Clients who have botulism should be quarantined within their home." e. "Parasitic diseases may not show up for 1 to 2 weeks after infection."
Todd Bishop, a Crew Resource Management expert, developed a five-step assertive statement process that emphasizes inquiry and advocacy in effective communication. Which of the following is not one of this five-step process?
a. State your concern. b. State the problem as you see it. c. State a solution. d. State the need for your solution.
The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart?
A) "Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms." B) "Client prioritizes personal hygiene in her daily routines and is proactive with skin care." C) "Client bathes more often than necessary and consequently experiences dry skin." D) "Client's level of personal hygiene is acceptable and age-appropriate."
The nurse is counseling a female college student at a rape crisis center who states that she was attacked by a male on campus. Which of the following is appropriate advice for this rape victim?
A) Encourage the victim to seek psychological treatment within 2 weeks. B) Counsel the victim to put the experience behind her as quickly as possible. C) Do not notify the police until there is positive evidence a rape has occurred. D) Encourage the victim to seek physical help and have a "rape kit" documented.