The nurse uses each of the following assessments during the course of every client's care, including:(Select all that apply) Standard Text: Select all that apply
1. Complete assessment
2. Focused assessment by body system
3. Focused assessment of a body part
4. Fontanel assessment
5. Pain threshold
1,2,3
Rationale: -
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The client is newly diagnosed as having a terminal disease and asks, "I'm going to die soon, aren't I?" What are the most appropriate statements by the nurse? Select all that apply
A) "You should ask your health care provider that question." B) "What have you been told by your health care provider?" C) "How do you feel about that?" D) "This is something I am not comfortable discussing." E) "No, you are not actively dying."
A nurse is discussing feeding practices with the mother of a 3-month-old infant. The mother describes propping the bottle on a blanket in the crib
Which is the highest priority consequence of this practice that the nurse should monitor when caring for the infant? A) Oral thrush B) Tongue infection C) Erosion of tooth enamel D) Ulcers in mouth
A nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate (MgSO4). Which assessment parameter is critical?
A. 24-hour urine output B. Asking the client about feeling depressed C. Hourly deep tendon reflexes (DTRs) D. Monitoring of serum calcium levels
MC Clinical Situation: Jane Smith, a 30-year-old obese female had a cholecystectomy (gallbladder removal) 3 days ago. Her gallbladder symptoms began 6 months ago, but the physician wanted her to lose weight before the surgery
She has developed a postoperative infection and now requires wound care and dressing changes. You are assigned to care for Mrs. Smith for your clinical experience. When placing the sterile 4x gauze pads on Mrs. Smith's incision, you did not cover the incision as you intended. You should A. Remove the gauze pads and replace them with new pads. B. Adjust the pads to cover the incision. C. Place an additional pad over the exposed section of the incision. D. Leave the gauze pads in place and apply an ABD over them.