The nurse is confronted with an ethical decision regarding a client's continuing care. Which of the following approaches can be used to reach a decision for this client? (Select all that apply.)
1. Medical indications
2. Client preferences
3. Quality of life
4. Health insurance plan
5. Contextual features
6. Integrated model
1, 2, 3, 5, 6
There are several approaches that can be used to help with ethical decision making. These approaches are medical indications, client preferences, quality of life, contextual features, and the integrated model. The client's health insurance plan is not used to help with ethical decision making.
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The family of a client in the ICU expresses their concern because their family member is confused and disoriented. The best explanation by the nurse is:
1. "This is expected in older clients with dementia." 2. "You can help us reverse this problem." 3. "You are visiting too much and disrupting care." 4. "The client might not recover from the confusion."
The nurse is using short, tapping strokes on the surface of the skin to create vibrations of underlying organs while assessing a client. This assessment technique would be considered to be:
a. inspection. c. percussion. b. palpation. d. auscultation.
A 56-year-old female patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect?
a. Poor skin turgor b. Recent weight gain c. Elevated urine ketones d. Decreased blood pressure
Two hours after taking a dose of penicillin, a patient arrives in the emergency department complaining of tightness in the throat, pruritus, and red wheals
During the physical assessment, the patient develops difficulty breathing, respirations 36/min, blood pressure 90/42, pulse rate of 120/min. The priority nursing action would be to a. administer diphenhydramine (Benadryl), because the patient is experiencing a moderate allergic reaction that should improve shortly. b. sit the patient up in bed, administer oxygen until the symptoms subside, and notify the prescriber. c. question the patient about any previous allergy to penicillin and report the symptoms to the prescriber. d. call for assistance, apply oxygen, administer epinephrine as ordered, and notify the prescriber.