The nurse has administered the Apgar screen tool to assess an older patient's family function status. Upon determining that the family functions at a 4, the nurse
a. prepares to administer a more detailed tool.
b. prepares to report reasonable suspicion of elder abuse.
c. asks the patient to identify specific family members to include in care planning ses-sions.
d. notifies social services that the family is not likely to be of much support to the pa-tient.
D
An Apgar score of 4 to 6 suggests a moderately dysfunctional family, one that should not be de-pended on to provide physical, financial, or emotional support to the patient.
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The nurse is evaluating care provided to a client recovering from surgery for colorectal cancer. Which outcomes indicate that care has been successful?
Select all that apply. A) Client reports pain level as an 8 on a rating scale of 0-10. B) Client has an hourly urine output of 45 mL. C) Client performs morning care with assistance. D) Client states family members will care for the ostomy at home. E) Client tolerates full liquid diet and is requesting solid food.
The nurse is preparing to assess a patient with Cushing syndrome. Which findings should the nurse expect to assess in this patient?
Select all that apply. 1. weight gain 2. auscultatory lung crackles 3. jugular vein distention 4. peripheral edema 5. hypotension
Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first?
a. Auscultate the heart sounds. b. Check the patient's temperature. c. Notify the patient's health care provider. d. Give the PRN acetaminophen (Tylenol).
Herpes zoster is caused by the varicella virus and has an affinity for:
a. sympathetic nerve fibers. b. parasympathetic nerve fibers. c. posterior root ganglia and posterior horn of the spinal cord. d. lateral and dorsal columns of the spinal cord.