Which does the nurse implement to begin the thoracic assessment of a client?
1. Percussion of the lateral thorax
2. Palpation of the anterior thorax
3. Measurement of respiratory rate
4. Inspection of the posterior thorax
4
4. The nurse begins a thoracic assessment by inspecting the posterior thorax to iden-tify any factors that can impair chest expansion or respiratory distress.
1. Lateral percussion is not used in a respiratory assessment because the biggest lung fields are across the client's back.
2. Palpation of the anterior thorax follows assessment of the posterior thorax.
3. Measuring the respiratory rate follows the posterior thoracic inspection.
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Nurses must be aware of cultural considerations when assisting clients with pain tolerance. Which statement made by the nurse indicates an understanding of cultural awareness?
1. "Nurses must know that all pain is the same no matter what culture the client comes from." 2. "Nurses must not ask probing questions about the client's pain, as this is considered inappropriate." 3. "Nurses should treat all clients the same regardless of cultural differences." 4. "Nurses must understand that different cultures deal with pain in very different ways. Nurses must not judge the client based on any misconceptions of pain and treatment of pain."
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care?
a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patient's left side. d. Teach the patient that the left visual deficit will resolve.
Which is a basic rule when writing a letter of resignation?
a. Avoid venting negative feelings. b. Honesty is the best policy; say how it is. c. List suggestions for agency improvement. d. Prior notice is highly overrated; just don't show up any more.
The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal?
A) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. B) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma. C) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased. D) Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear.