Which cognitive changes does the nurse recognize as being normal in an older patient? Standard Text: Select all that apply
1. Decline in the ability to draw
2. Decrease in size of vocabulary
3. Difficulty filtering out irrelevant information
4. Difficulty switching attention from one person to another
5. Needing to repeat information to the patient several times
1,3,4,5
Rationale: A decline in visuospatial task ability such as drawing declines with aging.
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A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation?
a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.
The nurse is caring for a baby with newly diagnosed renal disease. The nurse would anticipate diagnostic tests to evaluate functioning of which of the following sytems to be the highest priority?
1. Ears 2. Heart 3. Lungs 4. Joints
The nurse assesses a client with a below-knee amputation. Which assessment of the skin flap requires immediate action?
a. Pink and warm to the touch b. Pale and cool to the touch c. Dark pink and dry to the touch d. Pink and slightly moist to the touch
What would be a likely result of the development of a universally agreed-upon nomenclature and taxonomy for nursing clinical information and management data?
a. The inability to identify what the nursing staff actually does b. A failure to determine the impact nurses have on outcomes c. The establishment of appropriate reim-bursement for nursing activities d. A decrease in the number of nursing di-agnoses