The nurse is preparing to document care provided to a postpartum patient. What should the nurse consider when completing this documentation? (Select all that apply.)
A) Be clear
B) Chart facts
C) Summarize opinions
D) Date and time the entry
E) Write concise information
Ans: A, B, D, E
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The dementia unit nursing staff is informed that the entire unit will be redecorated in the next two weeks. Nursing staff tell the nurse manager that this will be a problem for the clients
What particular client need is addressed by their concern? A) Client safety B) Client comfort C) A stable environment D) Scheduling of admissions
A mother is concerned that her 8-month-old child does not have any teeth. The best response from the nurse would be:
1. "Teeth tend not to come in until around 18 months, so this is normal.". 2. "I understand your concern about the lack of teeth. I will make sure the doctor addresses your concerns.". 3. "This is nothing to worry about. Your child is still young, and the teeth will come in when they are ready.". 4. "Normal tooth eruption occurs by the one year mark. Continue to watch your child, and report to us if teeth have not come in by then.".
The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?
A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours
Which assessment is most important for the client who is taking stimulant laxatives?
a. Monitor bowel elimination daily. b. Monitor intake and output. c. Monitor signs and symptoms of fluid and electrolyte imbalance. d. Monitor heart rate and blood pressure every 4 hours.