Upon completing the patient history, which finding will cause the nurse to monitor for bleeding?
A. Increased intake of biotin
B. Increased intake of vitamin E
C. Decreased intake of folic acid
D. Decreased intake of vitamin B12
Answer: B. Increased intake of vitamin E
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The nurse clarifies that the stool softener is given as a part of routine post–myocardial infarction (MI) care in order to prevent:
a. bradycardia from straining at stool. b. fluid retention from retained bowel con-tents. c. respiratory difficulty from abdominal dis-tention. d. discomfort from painful gas.
On entering the room of a child in Buck's traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?
a. Child's heels are placed firmly against the foot of the bed. b. Head of bed is elevated 20 degrees. c. Weights are hanging freely. d. Ropes are on pulleys.
An older male adult who has activity intolerance due to pulmonary fibrosis barks orders and commands at the nursing staff when he cannot help himself. Which is the nurse's priority patient outcome for planning care to resolve these problems?
a. Verbalizes requests in calm, respectful, and appreciative manner b. Identifies potential triggers of anger and redirects energy positively c. Expresses an understanding of the need to balance rest and exercise d. Resolution of pulmonary fibrosis to restore baseline activity tolerance
The nurse is assessing an older adult client during a routine health maintenance visit. To assess the client's range of motion of the knees, which action by the nurse is appropriate?
A) Seat the client and extend the knee until the client alerts the nurse of severe pain. B) Seat the client and instruct to alert the nurse of any pain. C) Place the client prone and gently lift the entire leg. D) Have the client stand and extend the knee as far as it will go.