A client who is not fluent in English comes to the health center with vague complaints of back pains. Physical assessment findings include several old and fresh bruises over the upper part of the client's body
The client's spouse, who sits next to the client in the exam room, offers to answer questions and often finishes the client's sentences when the client is having trouble finding the appropriate words. The nurse should: A) Ask the spouse to remain in the waiting room while the client is being examined.
B) Contact the local authorities.
C) Encourage the spouse to remain with the client to provide information about the client's health, and to
translate as needed.
D) Alert hospital security to the potential for violence.
A
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A patient, age 63, has cancer of the left breast. After a modified radical mastectomy, she has been receiving chemotherapy. Her grandson, who visited a few days ago, now has varicella (chickenpox)
The nurse should observe her carefully for signs of a. herpes zoster. b. herpes simplex type I. c. herpes simplex type II. d. impetigo.
The nurse is obtaining a medication history from a client who is reporting erectile dysfunction. Which medication would the nurse identify as being least likely to contribute to the client's condition?
A) Spironolactone B) Cimetidine C) Ibuprofen D) Methyldopa
A patient who is being treated for hypovolemic shock is in an acutely ill state and unable to take food or fluids by mouth
The nurse knows that the patient's nutritional needs should not be neglected, however, and should advocate for which of the following? A) The initiation of total parenteral nutrition when the patient's condition stabilizes B) The initiation of parenteral or enteral nutritional support as soon as possible C) Administration of colloids in order to meet the patient's short-term nutritional needs D) Addition of multivitamins to the patient's intravenous solution
The nurse is caring for an 8-month-old infant. Which of the following is the best tool the nurse should use for evaluating pain in this infant?
A) FLACC scale B) Wong-Baker FACES C) Visual analog scale D) Any of the above