While assessing a client with smooth, taut, shiny skin in the calves and thighs, the nurse makes a 1 inch deep depression in the calf that is slow to disappear. The nurse charts that the client has:
1. +3 pitting edema of the calves.
2. mild edema in the calves of the legs.
3. fluid volume deficit.
4. hyponatremia.
ANS: 1
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A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________
a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance c. XII; percussing the sternomastoid and submandibular neck muscles d. XII; assessing for a positive Romberg sign
A nurse caring for a paralyzed patient who has been diagnosed with reflex incontinence should include which of the following preventative measures in the teaching plan with this patient?
A) Regular perineal care to prevent skin breakdown B) Kegel exercises to strengthen the pelvic floor C) Small frequent meals D) Limited fluid intake to prevent incontinence
Which statement is true about caregiving?
a. Dementia in an elder can cause grief in the caregiver comparable to the grief from the elder's death. b. Middle-aged adults and older parents reverse lifelong caregiving roles with in-creasing age. c. Older adults should relocate to the caregiver's home when long distances separate the two. d. Increasing numbers of adult children who are developmentally disabled become caregivers for their older parents.
An unconscious client who has just been involved in a motor vehicle accident is brought to the emergency department
Which presenting clinical manifestation makes the nurse suspi-cious of an opioid overdose rather than increased intracranial pressure as a cause of the un-consciousness? A. Pinpoint pupils B. Respiratory depression C. Hyporeflexive deep tendon reflexes D. Evidence that the client has vomited