The best method to assess the restoration of fluid volume in a patient who has been dehydrated is to
a. monitor blood pres-sure c. check weight daily
b. observe changes in skin turgor d. assess oral mucous membranes
C
Changes in the body's total fluid volume are indicated by weight. Blood pressure measurements can be used to reflect extracellular fluid status and the degree of fluid volume deficit. Assessing skin turgor and mucous membranes are unreliable indicators of adequate fluid volume.
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As the nurse is collects data for a newly admitted client, it becomes clear that the client is confused. The nurse notes interventions appropriate for promoting orientation as:(Select all that apply) Standard Text: Select all that apply
1. Address the client by name 2. Assign a variety of caregivers 3. Speak quickly so the client does not have time to argue 4. Tell the client when you are leaving and when you will return 5. Encouraging the client to wear familiar clothing
The nurse informs a client that her plaster cast is dry because the nurse has assessed that the cast is
a. cold to the touch. b. dull on percussion. c. gray in color. d. odorless.
A patient has infarct of the right anterior cerebral artery. The nurse would attribute which assessment findings to this condition? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. The patient is incontinent of urine. 2. The patient cannot move the right leg. 3. The patient does not respond to light touch on the feet. 4. The patient cannot speak. 5. The patient has paralysis of the right arm.
The client preparing to go home after a radical neck dissection for cancer is crying
When the nurse asks why he is crying, the client writes, "I know I shouldn't cry because this surgery may well save my life, but I can't believe how changed my appearance is." What is the nurse's best response? A. "It is all right to cry. Mourning this loss is important in getting past this point." B. "You're right. It is silly to carry on like this when the surgery may cure you." C. "Would you like to talk to someone who also has had a laryngectomy?" D. "How have you coped with difficult situations in the past?"