The nurse is entering the room to assess a newly admitted client. Which of the following best describes the purpose for a general survey? The general survey:
1. allows for vital signs prior to starting exam.
2. provides an opportunity for the client to relax before the exam.
3. yields information to guide the physical assessment.
4. provides the information necessary for the diagnosis.
3
Rationale 1: Vital signs are not part of the general survey. The general survey consists of four major observations: physical appearance, mental status, mobility, and behavior.
Rationale 2: The purpose of the general survey is to allow the nurse the opportunity to gather clues to guide the rest of the assessment; the purpose is not to give the client an opportunity to relax.
Rationale 3: The general survey allows the nurse to observe the client and gain clues to guide the remainder of the assessment.
Rationale 4: The general survey does not provide the necessary information to identify client problems or nursing diagnosis, but rather serves as a guide for a more detailed assessment.
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Nurses that think family recognize that long-term stress and burdens may emerge when a family is giving care to an ill family member. Research findings have shown:
1. Nurses can provide various types of support that ease distress of caregiving. 2. A positive relationship between caregiving and depression. 3. A positive link between caregiving and physical health effects. 4. All of the above.
A patient is admitted with acute hepatic dysfunction caused by chronic liver disease. Which of the following should the nurse assess for in this patient?
1. NSAIDs use 2. alcohol use 3. protein intake 4. treatment for hypertension
Specific Gravity of urine
What will be an ideal response?
A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities
The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction? a. "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." b. "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." c. "Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet." d. "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."