The nurse is establishing goals with a client. Which of the following best describes a goal?
a. It is measurable and has a time limit.
b. It is a broad statement that describes the intended change in the client's behavior or response.
c. It is a direct result of analysis of collected data.
d. It includes both objective and subjective data.
ANS: B
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A client is grimacing and with fists clenched states, "I'm in excruciating pain." Which of these entries indicates correct documentation of the client's affect?
a. "Client is angry." b. "Client is in a hostile mood." c. "Client states, ‘I'm in excruciating pain.' Grimacing, clenched fists noted." d. "Client is uncooperative during the assessment process."
A client is admitted with the diagnosis of fever of unknown origin. Which diagnostic tests does the nurse anticipate for this client?
Select all that apply. A) CT scan of the abdomen B) Chest x-ray C) Urinalysis D) Complete blood count E) Bone scan
What is the primary reason for the preterm infant's inability to conserve heat?
a. A smaller surface area in relation to body weight b. An increased tendency to shiver when cold stressed c. Increased vasoconstriction of surface blood vessels d. Lack of subcutaneous fat that would provide some insulation
A nurse is working with a client who has overflow incontinence, helping the client to achieve bladder control. Which intervention is most likely to be effective in stimulating initiation of voiding for this client?
A. Stroking the medial aspect of the thigh B. Using intermittent catheterization C. Providing digital anal stimulation D. Using the Valsalva maneuver