The home health nurses visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the health care provider?
1. Bronchial breath sounds
2. Increased tactile fremitus
3. Low-pitched wheezing (rhonchi)
4. Pleural friction rub
Answer: 4. Pleural friction rub
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A child is hospitalized with a serious bacterial infection. Which assessment finding indicates that the goals for a priority nursing diagnosis have been met?
A. Intact skin integrity B. Normal temperature C. Stable weight D. Urine output of 1 mL/kg/hour
Using a Snellen chart, the nurse would credit a client with reading the line of print if the client has correctly read more than
a. 50% of the characters. b. 60% of the characters. c. 80% of the characters. d. 90% of the characters.
A patient tells the nurse that one result of his chronic stress is that he has considerable fatigue. He usually sleeps from 11:00 PM to 6:30 AM
He reports he now sets his alarm to give himself an extra 30 minutes of sleep each morning but feels no better and is rushed for work. Which nursing response would best address the patient's concerns? a. "You may need to speak to your doctor about taking a sedative to help you sleep.". b. "Exercising just before retiring for the night may help you to sleep better.". c. "Perhaps going to bed a half hour earlier would work better than sleeping later.". d. "A glass of wine in the evening might take the edge off and help you to rest.".
As part of a comprehensive assessment of a newly admitted client, the nurse is performing an examination to determine whether a client is experiencing abnormalities in thinking and reasoning ability, feelings, or behavior
What type of examination is this nurse conducting? A) Mental status examination B) Psychosocial examination C) Psychoses examination D) Health examination