Which patient would require special precautions when the nurse is performing a digital rectal exam?
a. Patient with chronic obstructive pulmonary disease (COPD)
b. Patient with diabetes
c. Patient with Parkinson disease
d. Patient with congestive heart failure
ANS: D
Persons with a cardiac history may experience vagal stimulation and have a sudden drop in heart rate, resulting in syncope.
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A nurse is working with a local agency to provide care to the inadequately insured by helping to staff an after-hours clinic. This nurse is demonstrating which value of client advocacy?
1. The client has the right to make choices and decisions. 2. The client has the right to expect a nurse–client relationship based on shared respect. 3. The nurse has the responsibility to ensure the client has access to health care services 4. The nurse has the responsibility to to make choices and decisions.
A unit has experienced several violent outbursts that have resulted in the forcible restraint of patients. On review, each violent event and all crisis management strategies were appropriately followed
To maximize staff efficiency the nurse manager should: a. determine the institution's policies regarding the management of crisis situations should be reviewed in mandatory staff education sessions. b. schedule staff breaks at intervals that allow staff members to leave the unit and relax while discussing the problems in the current milieu. c. invite a team of experts to evaluate crisis management on the unit for 1 month to determine whether any procedures are being unintentionally omitted. d. schedule a multidisciplinary team education meeting and invite a distinguished expert who can help staff members understand that they managed each crisis appropriately.
Which of the following statements by the nurse reflects a need for immediate follow-up regard-ing the physical effects of chronic pain on body function?
1. "His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working." 2. "Please take his pulse and blood pressure, and let me know if they are elevated above his normal baselines." 3. "If his pulse and blood pressure are above his normal baseline, let me know, and I will medicate him for pain." 4. "Unmanaged pain usually manifests itself in both an elevated pulse and blood pressure."
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing
A) Anemia B) Malnutrition C) Poor tissue perfusion D) Congestive heart failure