The nurse is assessing a pregnant client who is at 29 weeks gestation. The nurse notes that the client's blood pressure is 160/90 and documents that the clonus was noted after assessing the patellar reflex. Which assessment findings led the nurse to document this finding?
A. There was no response when the area directly above the knee was struck with the percussion hammer.
B. The nurse noted an extension of the leg when the percussion hammer touched the area above the knee.
C. The client complained of pain when the foot was dorsiflexed.
D. The client's foot tapped against the nurse's hand when it was dorsiflexed.
Answer: D
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A patient of the Austrian-American Jewish tradition tells the nurse how to treat boils. What will this patient most likely explain to the nurse?
A. Apply a fried chopped onion compress to the area. B. Press cold tea bags to the area. C. Apply a flaxseed poultice to the area. D. Place hot Epsom salts on the area.
What order would be most appropriate for these statements involving development of a focused clinical question, progressing from lowest level to highest level?
A. What is the population of interest? B. To what will this intervention be compared? C. What is the intervention of interest? D. How will the intervention make things better or worse? a. A, B, C, D b. D, C, B, A c. D, B, C, A d. A, C, B, D
A client with a body temperature of 104°F is entering the flush phase of the fever. To assist this client, the nurse will:
1. Cover the client with warm blankets. 2. Restrict fluids. 3. Cover the client with a light sheet. 4. Provide warmed intravenous fluids.
Reviewing a client's record, the nurse notes that the client has a goiter. Which priority question should the nurse include in the focused interview?
A. "Where do you purchase your medication?" B. "What type of salt do you use in your diet?" C. "How long have you had this problem?" D. "Do you work around chemicals?"