Which of the following would the nurse document as an abnormal finding with lymph node assessment?
A) Diameter: 0.75 cm
B) Mobile
C) Tender
D) Discrete
C
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A nurse will be providing care for a female patient who has a diagnosis of heart failure that has been characterized as being primarily right sided
Which of the following statements best describes the presentation that the nurse should anticipate? The client A) has a distended bladder, facial edema, and nighttime difficulty breathing. B) complains of dyspnea and has adventitious breath sounds on auscultation (listening). C) has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain. D) has cyanotic lips and extremities, low urine output, and low blood pressure.
A nurse identifies a nursing diagnosis of Constipation related to the effects of the prescribed cholinergic blocking drug. Which of the following would the nurse expect to include in the client's plan of care? Select all that apply
A) Encouraging the intake of a diet high in fiber B) Decreasing the dosage of the cholinergic blocking medication C) Increasing client's fluid intake to at least 2000 mL daily D) Withholding the drug until the client resumes usual bowel pattern E) Encouraging ambulation and exercise as appropriate
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°
The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient's plan of care? a. Frequent neurological assessments b. Side to side position changes c. Range of motion to extremities d. Frequent oropharyngeal suctioning
The nurse identifies jaundice in an assigned client. Which assessment technique is the nurse using?
A) Inspection B) Palpation C) Auscultation D) Percussion