The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for abdominal skin tenderness and temperature
Which of the following techniques would the nurse use to collect this data?
a.
Inspection
b.
Percussion
c.
Palpation
d.
Auscultation
ANS: C
Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness. Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems. Percussion involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Vibration is reflected by the tissues, and the character of the sound heard depends on the density of the structures that reflect the sound.
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A client is diagnosed with acute allergic contact dermatitis over 25% of his body. The nurse realizes that which of the following will most likely be prescribed for this client?
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A patient in the process of being involuntarily committed demands to be evaluated by his own private psychiatrist. To preserve the patient's rights, the treatment team must:
a. stop the commitment process. b. notify the unit psychiatrist immediately. c. provide access to the private psychiatrist. d. determine why the patient is resisting staff care.
Which of the following nursing interventions is the best example of the implementation step of the nursing process?
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