The nurse is conducting a health history for a client with a respiratory disorder. What will be included in this assessment?
1. Lifestyle.
2. Presence of cough.
3. Sputum production.
4. Pain.
5. Diet.
Correct Answer: 1,2,3,4
Rationale 1: A comprehensive nursing history relevant to oxygenation status should include data about lifestyle.
Rationale 2: A comprehensive nursing history relevant to oxygenation status should include data about the presence of a cough.
Rationale 3: A comprehensive nursing history relevant to oxygenation status should include data about sputum production.
Rationale 4: A comprehensive nursing history relevant to oxygenation status should include data about pain.
Rationale 5: A comprehensive nursing history relevant to oxygenation status does not include data about diet.
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The nurse is assessing an older adult admitted with pancreatic insufficiency. While assessing for the presence of malabsorption, the nurse recalls that malabsorption may be extraintestinal in the older adult and may include the symptoms of:
A) Shortness of breath and hypervolemia B) Fatigue and confusion C) Pruritus and muscle rigidity D) Darkening of skin pigmentation and tremors
The nurse has investigated safety hazards and recognizes that which one of the following state-ments is accurate regarding safety needs?
1. Bacterial contamination of foods is uncontrollable. 2. Fire is the greatest cause of unintentional death. 3. Carbon dioxide levels should be monitored in home settings. 4. Temperature extremes seldom affect the safety of clients in acute care facilities.
A client has been diagnosed with post-traumatic stress syndrome and has difficulty sleeping because of recurrent nightmares. In working with this client to overcome the problem, the nurse may implement which of the following as part of therapy?
1. Guided imagery 2. Hypnotherapy 3. Yoga 4. Meditation
A client with cirrhosis of the liver asks the nurse why they are at risk for bleeding. Which response should the nurse provide the client?
A. "The liver is injured and unable to manufacture platelets." B. "The liver thickens your blood so it is less likely to clot." C. "The liver is injured and cannot make clotting factors." D. "The liver is breaking down your clotting factors too quickly."