The nurse documents which information in the patient's history?
a. The patient's skin feels warm to the touch.
b. The patient is scratching his arm.
c. The patient's temperature is 100° F.
d. The patient complains of itching.
ANS: D
You might also like to view...
Sepsis is an evolving process, with neither clearly definable clinical signs and symptoms nor predictable progression
As the ICU nurse caring for a patient with sepsis, the nurse knows that tissue perfusion declines during sepsis and the patient begins to show signs of organ dysfunction. What sign would indicate to the nurse that end-organ damage may be occurring? A) Urinary output increases B) Skin becomes warm and dry C) Adventitious lung sounds occur in the upper airway D) Heart and respiratory rates are elevated
An older adult client is trialing the use of an infrared listening device (IRLD). How does this device have the potential to increase the client's ability to hear?
A) The device directs sounds into one ear rather than into both ears B) The device increases the volume of foreground noises C) The device enhances the function of the auditory nerve D) The device converts light into an auditory stimulus
The nurse realizes that a client with teenage children might have the additional developmental task of:
a. adjusting to parenthood. b. extended caring to aging parents. c. accepting changes in generational roles. d. reviewing life.
A patient has decreased cardiac output. Which physiologic process in the kidneys would be most affected by this disease process?
a. Glomerular filtration b. Tubular reabsorption c. Tubular secretion d. Osmotic pressure