The nurse has completed a physical assessment with an older patient. Which assessment finding suggests the presence of deep-venous thrombosis?
1. Two plus palpable pedal pulses
2. Shortness of breath after activity
3. Swelling in one leg with pitting edema
4. Bilateral calf tenderness after walking up a flight of stairs
3
Rationale: Two plus palpable pedal pulses is a normal assessment finding.
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The nurse is caring for a client who is a single mother of two young children, has no financial or parental support from her ex-husband, is troubled by her financial circumstances and future, and works at a local fast-food restaurant
She is seeking help for depression. What is the nurse's best action? a. Assist the client in seeking educational and/or vocational programs for single parents. b. Encourage the client to explore her feelings related to the reasons for her divorce. c. Persuade the client to contact her ex-husband for financial and parental support. d. Share information with the client regarding support groups for single mothers.
If the nurse aggressively says to a patient, "Why couldn't you have asked me to give you your pain medication when I was in here earlier?" the patient is most likely to feel:
a. angry. b. that his needs are met. c. humiliated and unworthy. d. that his request will be granted.
A patient presents to the clinic with complaints of breast pain that is continuous. Which assessment question is most pertinent?
1. "Are you taking any vitamins?" 2. "Have you had back pain recently?" 3. "Has anyone in your family had breast cancer?" 4. "How old were you when your periods started?"
The nurse instructs a client with type 2 diabetes on foot care. In addition to keeping the feet clean and dry, the nurse may also offer the following advice:
A) "Wear nylon socks to keep your feet warm." B) "Walk on bare feet to promote circulation." C) "File your toenails straight across. Avoid using scissors." D) "Wear open-toe shoes to avoid pressure around toenails."