An elderly client with a high temperature is hallucinating. The nurse realizes this client is most likely experiencing:
a. acute confusion.
b. delirium.
c. dementia.
d. depression.
ANS: B
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When caring for a multiple-organ trauma victim, the nurse must prevent early complications of
A) sepsis. B) head injuries. C) hemorrhage. D) Both b and c are correct.
The nurse working at a community health center is caring for a client who required bilateral amputation of both arms. How would the nurse measure pulse rate?
1. By palpating the temporal pulse 2. By palpating the carotid pulse 3. By palpating the brachial pulse 4. By palpating the femoral pulse
Which of the following are examples of common factors that may influence assessment priorities? Select all that apply
A) a patient's diet and exercise program B) a patient's standing in the community C) a patient's ability to pay for services D) a patient's developmental stage E) a patient's need for nursing
A nurse has completed the assessment for a patient who has a maladaptive response to eating regulation
Findings include: height, 5 feet 3 inches; current weight, 80 pounds with weight loss of 30% of body weight; poor skin turgor; lanugo; amenorrhea of 6 months' duration; and admits to restricting intake to 350 calories daily. These assessment findings are most consistent with the medical diagnosis of: a. bulimia nervosa. b. anorexia nervosa. c. binge-eating disorder. d. disturbed body image.