A 77-year-old client with a history of COPD has undergone a hernia repair. Which of the following expected outcomes should be the priority focus for the nurse?
a. The client ambulates 10 feet with assistance.
b. The client tolerates a clear liquid diet.
c. The client rates his pain as 2 to 3 on a 10-point scale.
d. The client has normal auscultated breath sounds"
Answer: d. The client has normal auscultated breath sounds"
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A severely depressed client's risk for self-directed violence increases when:
1. A no-suicide contract is made with the client. 2. The client is encouraged to discuss feelings. 3. The client is asked to discuss the suicide plan. 4. The antidepressant medication begins to work.
As death approaches, a patient with AIDS says, "I do not have enough energy for many visitors anymore, and I am embarrassed about how I look. I only want to see my parents and sister.". What action should the nurse take?
a. Support the patient to share the request with the parents and sister. Suggest that they inform the patient's friends of the request. b. Encourage the patient to reconsider this decision. Interested and caring friends can be sources of support. c. Suggest that the patient discuss these wishes with the health care provider. d. Place a "No Visitors" sign on the patient's door.
Which result for a 30-year-old patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider?
a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep
The nurse is making a cultural assessment of a client. The most important data about a client's cultural beliefs are:
A) Objective data about the culture. B) Subjective data from the client. C) Subjective data from the family. D) Subjective data from society.