The nurse wants to assess the apex of a client's right lung. Which of the following locations should the nurse place the stethoscope to assess this area on the client?
1. Intercostal space 6th rib near the sternum
2. Intercostal space 4th rib near the axillary line
3. Below the scapula
4. Near the right clavicle
4
Rationale 1: The apex of each lung is slightly superior to the inner third of the clavicle.
Rationale 2: The apex of each lung is slightly superior to the inner third of the clavicle.
Rationale 3: The apex of each lung is slightly superior to the inner third of the clavicle.
Rationale 4: The apex of each lung is slightly superior to the inner third of the clavicle.
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The nurse is explaining to the UAP that the patient is on a full-liquid diet. Which statement by the UAP indicates a need for reorientation?
a. "I can give the patient orange juice." b. "I can give the patient yogurt." c. "I can give the patient oatmeal." d. "I can give the patient milk."
The nurse is planning care for a client admitted with a new diagnosis of bipolar disorder. During the manic phase of the disorder, the nurse plans interventions that decrease the risk for violence to others, which would include:
1. encouraging the client to join a basketball game. 2. encouraging the client to participate in group activities. 3. encouraging activities that minimize stimuli. 4. responding to agitation by restraining the client.
A patient with osteoarthritis in both knees and shoulders states that she cannot manage her household tasks without pain. Which is the most appropriate nursing diagnosis for this patient?
a. Ineffective coping, related to pain b. Risk for disuse syndrome c. Impaired physical mobility, related to pain d. Activity intolerance, related to pain
A known contraindication to receiving a second dose of a pertussis-containing vaccine is:
a. Chest pain b. Encephalopathy c. Altered mental status d. Shortness of breath