A nurse assesses an elderly patient brought to the emergency department by a grandchild who found the patient wandering in the front yard saying, "I can't find my way home." The patient is confused and unable to answer questions
Select the nurse's next action. a. Document the confusion. Obtain other assessment data from the grandchild.
b. Record the patient's answers to questions on the hospital assessment form.
c. Ask a more experienced nurse to perform the assessment interview.
d. Call for a mental health advocate to support the patient's rights.
A
When the patient (primary source) is unable to provide information, secondary sources should be used, in this case the granddaughter. Later, more data may be obtained from other relatives or neighbors who are familiar with the patient.
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A nursing student who is preparing to care for a postoperative patient with deep vein thrombosis asks the nurse why the patient must take heparin rather than warfarin. Which response by the nurse is correct?
a. "Heparin has a longer half-life." b. "Heparin has fewer adverse effects." c. "The onset of warfarin is delayed." d. "Warfarin prevents platelet aggregation."
The nurse is teaching prenatal clients about avoiding substances or conditions that can harm the fetus. Which should the nurse include in the teaching session? (Select all that apply.)
a. Elimination of use of alcohol b. Avoidance of supplemental folic acid replacement c. Stabilization of blood glucose levels in a diabetic client with insulin d. Avoidance of nonurgent radiologic procedures during the pregnancy e. Avoidance of maternal hyperthermia to temperatures of 37.8 ° C (100 ° F) or higher
The nurse explains that the tool that allows the evaluation of core function in a resident in a long-term facility is the __________ __________ __________
Fill in the blank with the appropriate word.
The student nurse has been assigned to four clients. The student nurse has to prepare care plans for the client assignment and incorporate Erikson's psychosocial development concepts
Which client should the student nurse recognize as most likely to be in the phase of stagnation? A) Teenage college student B) Early adulthood client C) Middle-aged adult client D) Older-aged adult client