Which of the following is an example of a problem that requires recording on the patient's problem list?
a. Common age variations
b. Expected findings
c. Problems needing further evaluation
d. Minor variations
C
Any problem is worth noting on the patient problem list, even if the cause or significance is un-known. Common age variations, expected findings, and minor variations within normal limits should not be classified as a problem.
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While teaching a patient, the nurse explains that cardiac functioning has both a mechanical and an electrical component. What is the best way to assess the mechanical function of the heart?
A) Blood pressure B) Pulse C) Membrane potential D) Cardiac monitor pattern
Gt
What will be an ideal response?
An 81-year-old client is being rehabilitated in an inpatient setting following her recovery from the acute stages of a stroke. The stroke resulted in dysphagia, which creates a risk of what respiratory problem?
A) Increased viscosity (thickness) of secretions B) Aspiration of food or fluid C) Increased quantity of secretions D) Laryngeal atrophy
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache
The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the physician of the patient's blood pressure.