The orientation phase during the assessment interview is a brief exchange to establish the interview's purpose, the examination procedures, and the:
1. need for a legally binding contract.
2. need to tape record the session for accuracy.
3. nurse's role in the nurse-client relationship.
4. process for cost-effective delivery of health care services.
ANS: 3
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A client who is receiving diuretic therapy comes to the clinic for a follow-up visit. The client states that his mouth is often dry and that he is "urinating like there is no tomorrow."
Assessment reveals dry mucous membranes and decreased skin turgor. Which nursing diagnosis would the nurse most likely identify? A) Risk for Injury B) Risk for Deficient Fluid Volume C) Impaired Urinary Elimination D) Deficient Knowledge
A pregnant client plans to eat twice as many complex carbohydrates because of "eating for two." Which response should the nurse make to this client?
a. "That is correct for later in the pregnancy." b. "Carbohydrate needs increase, but not by that amount." c. "That is correct; just make sure it is mostly complex carbohydrates." d. "Space your carbohydrate intake throughout the day to avoid spikes in blood glucose."
A nurse was assigned to care for a client who was speaking with his young daughter in an Asian language. Because the nurse spoke only English, which of the following actions should be taken by the nurse?
a. Ask the young daughter whether she knew English and could translate. b. Ask the young daughter whether the client's wife was available to translate. c. Call the nursing office to see whether any nurse in the hospital spoke the client's language. d. Check the hospital resource manual for the telephone number of a translator who spoke an Asian language.
Who coordinates the efforts of a lift team when moving a patient?
a. The patient's primary nurse b. The person who has come to offer assistance c. The person who has the heaviest load when lifting d. The assistant who is positioned at the head of the patient's bed