A pregnant client confides to the nurse that she is eating laundry starch daily. The nurse should assess the client for which of the following?
1. Alopecia
2. Weight loss
3. Iron deficiency anemia
4. Fecal impaction
3
Explanation: 3. Iron deficiency anemia is the most common concern with pica. The ingestion of laundry starch or certain types of clay may contribute to iron deficiency by replacing iron-containing foods from the diet or by interfering with iron absorption.
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A patient is on call to the OR for an aortobifemoral bypass and the nurse administers the ordered preoperative medication. After administering a preoperative medication to the patient, what should the nurse do?
A) Encourage light ambulation. B) Place the bed in a low position with the side rails up. C) Tell the patient that he will be asleep before he leaves for surgery. D) Take the patient's vital signs every 15 minutes.
The nurse is caring for a client who returns to the unit following transurethral resection of the prostate due to prostate cancer with a three-way Foley catheter in place
The client states that he has the urge to urinate and wants the catheter removed. The nurse knows that this feeling is caused by spasms. Which response by the nurse is the most appropriate? A) "This must be a complication, because the Foley catheter is supposed to evacuate clots that cause the sensation you are describing." B) "The spasm is an unexpected finding because the procedure does not invade the urethra." C) "The sensation is caused by the silicone used in the catheter. I will speak to the doctor about switching to a different catheter." D) "This is an expected sensation, but the Foley catheter must remain in place."
The nurse is admitting a 59-year-old patient to the medical-surgical unit after a diagnosis of cellulitis of the calf. What factors does the nurse know impact the processes of inflammation, repair, and replacement? (Mark all that apply.)
A) Severity of the injury B) Social relationships C) Condition of the host D) Familial support E) Nature of the injury
During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present?
a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein