A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient's condition as
a. moderate heart failure.
b. severe heart failure.
c. congestive heart failure.
d. negligible heart failure.
B
Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest.
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The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply
a. Develops over a short period. b. Person is experiencing apraxia. c. Person is exhibiting memory impairment or deficits. d. Occurs as a result of a medical condition, such as systemic infection. e. Person is experiencing agnosia.
The family of an older patient with Alzheimer's disease does not want to discuss long-term care placement for at least "a few years." How should the nurse respond to the family?
1. "Long-term care placement is inevitable with this diagnosis." 2. "It often takes a year for an individual with Alzheimer's disease to be admitted." 3. "Talking about it now gives you time to think about locations and make a decision." 4. "By providing this information now, we will not need to address these concerns later."
When assessing the axillae of the patient during the breast examination, the nurse should:
A) Reach high towards the apex of the axilla. B) Palpate the lower border of the pectoral muscle. C) Feel along the upper humerus. D) Feel inside the posterior axillary fold muscle.
A critically ill client has a fever. By which percent should the nurse adjust the energy expenditure calculation for every degree F for this client?
a. 5% b. 7% c. 12% d. 15%