The nurse is preparing to ambulate a patient who sustained burns over 20% of his lower extremities. Which intervention is most important to facilitate the success of the patient's ambulation?
1. Transfer the patient to a chair before ambulating.
2. Apply compression wraps to the lower extremities before getting out of bed.
3. Be certain the patient is well hydrated before ambulation.
4. Have the patient perform incentive spirometry.
Answer: 2
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A patient who has been depressed for the past several months presents in the clinic stating, "I'm at the end of my rope.". Which of the following inquiries would be most effective to use for assessing suicide risk?
a. "You seem very depressed and stressed. What is that like for you? What sort of feelings are you having when you say that?" b. "Tell me more about what you mean when you say you're at the end of your rope—are you thinking about killing yourself?" c. "Tell me about your family history. Do you have relatives or ancestors who suffered from depression?" d. "Tell me about your depression and being at the end of your rope; what are you thinking and feeling?"
You are caring for a patient with acute renal failure. What is the most common clinical manifestation of acute renal failure?
A) Decrease in BUN B) Anuria C) Oliguria D) Decrease in serum creatinine
The nurse applies an actual nursing diagnoses when selecting:
1. Ineffective Breathing Pattern 2. Risk of Infection 3. Readiness for Enhanced Nutrition 4. Readiness for Enhanced Family Coping 5. Anxiety
The nurse is aware that the overuse of direct questions can:
a. get a lot of information quickly. b. help the patients organize their thoughts. c. get minimum response answers of "yes" and "no." d. make patients think that they are contributing to their health care.