The nurse evaluates an improvement in the patient's heart failure (HF) status based on what assessment finding?
A) Using fewer pillows to sleep
B) Increased skin turgor
C) Heart rate regular
D) Improved mental status
A
Feedback:
The degree of HF is often calculated by the number of pillows required to get relief (e.g., one-pillow, two-pillow, or three-pillow orthopnea). Fluid overload is associated with HF so skin turgor is not an indicator of improvement. Regular heart rate and normal cognition can be found with acute flare-ups of HF so these findings would not indicate improvement.
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The mother of a female preschool-age child is concerned that the child is developing an unhealthy attachment to her father. About which behavior should the nurse instruct the mother?
A) Electra complex B) Oedipus complex C) Freudian complex D) Sexual identification complex
When providing client care the nurse demonstrates practices that are designed to provide legal protections from liability. Which actions is the nurse demonstrating?
1. Checking the client's name band prior to the administration of a preoperative medication 2. Asking for help when moving a comatose client because the client can not be safely handled by one nurse 3. Attending an in-service on the appropriate use of a new piece of equipment used in the facility 4. Delegating only those tasks that he or she can't personally perform 5. Reviewing the five rights of medication administration when the client states, "This doesn't look like my usual pill"
The nurse is making a home care visit for the first time to a patient recently discharged after hip replacement surgery. Which of the following, if observed in the home, would the nurse document as safety concerns? (Select all that apply.)
a. The patient has a large birdcage sitting on the floor in the middle of the living room. b. The hallway between the bedroom and bathroom is partially blocked by a cedar chest. c. Smoke detectors are located in the kitchen and near the bedrooms. d. A bathmat towel is on the floor in front of the tub. e. The patient's recliner faces the television. f. A safety bar has been installed in the shower.