An older adult patient experienced a fall during the previous night shift, and the care team suspects that the patient may be experiencing orthostatic hypotension
When assessing this patient for postural changes in blood pressure (BP), the nurse should:
A) Record the patient's standing, sitting and lying BPs in prompt succession while assisting the patient in transitions
B) Ask the patient to begin by adopting the position that most often causes him or her to feel dizzy then assess BP in a variety of positions
C) Take BP readings when the patient is lying, sitting, and standing with a minimum period of 30 minutes between each measurement
D) Assess the patient's BP in supine, feet dangling, and then standing positions with 1 to 3 minutes of waiting between each reading.
D
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While instructing a patient with ascites on dietary modification, the nurse will discuss the patient's need to restrict:
A) Potassium B) Sodium C) Calcium D) Glucose
A postpartum patient is upset that the baby was born with a congenital port-wine birthmark on the skin of the upper part of the right side of the face. What should the nurse explain to the mother about this birthmark?
A) "The birthmark is a part of a syndrome that can be cured with medication.". B) "The birthmark can be removed surgically so the child will develop normally.". C) "The birthmark is a concentration of melanin in the skin and causes cosmetic problems.". D) "The baby may have some numbness on the left side of the body because of the birthmark.".
A patient reports hearing noises when alone in a quiet room. What action should the nurse take?
1. make sure the patient is referred to a psychiatrist 2. document that the patient has a mental illness 3. ask if the patient experiences any visual disturbances 4. explain to the patient that this is not unusual
The nurse has completed a comprehensive assessment of a 16-year-old client who has been admitted for treatment for presumptive pelvic inflammatory disease. The client reported that she has been living on the streets with a 27-year-old male
She is curled up in the fetal position in bed, and when asked about her pain level, she cries out that she is in severe pain, that is "way over the top" of a 1-to-10 pain scale. She pulls away and flinches when any part of her body is touched. She is febrile and tachycardic. She has been examined and had all necessary labs sent off from the emergency department, and IV antibiotics were started. Since the client has already begun definitive medical treatment for her presumed infection, the nurse identifies the nursing diagnosis of acute pain related to possible pelvic inflammatory disease, and decides that this is the highest priority to address at this time. The appropriate outcome for this nursing diagnosis is: 1. The client's comfort will be achieved and maintained. 2. The client will be discharged to a safe living environment. 3. The client's infection will be eradicated. 4. The client will be reunited with her parents.