When a client is admitted to the hospital with clinical manifestations of left ventricular heart failure, the nurse would question the client about
a. abdominal pain.
b. breathlessness.
c. leg swelling.
d. nausea.
B
To some degree, exertional dyspnea occurs in all clients. Therefore the nurse should elicit a de-scription of the degree of exertion that results in the sensation of breathlessness from the client with clinical manifestations of heart failure.
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The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should the nurse's next assessment be?
a. Fullness of the bladder b. Amount of lochia c. Blood pressure d. Level of pain
A 10-year-old child, who has been placed in a foster home after being removed from parental
contact because of abuse, demonstrates a high level of apprehension and overreaction to environmental stimuli. The foster parents ask the nurse what measures they can use to help the child. The nurse should recommend (more than one answer may be correct) A. using a calm manner and low voice. B. avoiding repetition in what is said to the child. C. structuring and maintaining simplicity in the environment. D. minimizing opportunities for exercise and play. E. explaining and reinforcing reality to avoid distortions.
A child with sickle cell disease, in splenic sequestration crisis, is being admitted. The nurse should assign this patient to a:
1. Semi-private room. 2. Reverse isolation room. 3. Contact isolation room. 4. Private room.
A client who had a long-leg cast applied last week reports to the clinic nurse, "I can't seem to catch my breath and I feel a bit lightheaded." Which is the priority action of the nurse?
a. Listen to the client's lungs and check the client's blood glucose level. b. Give the client 2 L of oxygen via nasal cannula and check vital signs. c. Check the client's pulse oximetry and ar-range emergency transfer to the hospital. d. Reassure the client that it takes much more effort to move with a long-leg cast.