The nurse notes a client's neck veins are distended when sitting upright. This finding is indicative of which of these conditions?
a. ascites c. pulmonary hypertension
b. decreased renal out-put d. right-sided heart failure
D
Objective data for a client who has cardiovascular symptoms include a head-to-toe assessment of the skin; observation of neck veins, respirations, heart sounds, abdomen, and extremities; and observation of peripheral pulses, ascites, cold or mottled extremities, or edema in the feet, ankles, or legs. Distention of the neck vein when sitting may be indicative of right-sided heart failure.
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A nurse is providing discharge instructions to the family of an older adult patient who is unable to get out of bed
What should the nurse instruct the family regarding the most effective way to prevent urinary incontinence associated with immobility? a. Use absorbent underpads. b. Set up a toileting program. c. Restrict fluid intake to 500 mL per 24 hours. d. Restrict fluids after dinner and throughout the night.
A nurse is helping a client feed her newborn, who has a cleft lip and palate. Which of the following guidelines would the nurse include when teaching the client about feeding an infant with a cleft palate?
A) Placing the infant in the supine position B) Using special cleft palate nipples C) Reducing the size of the hole in the nipple D) Placing the Lamb's nipple over the defect
Hildegarde Peplau wrote about the phases of the nurse-client relationship. The phase exemplified by a psychiatric nurse assisting a client to practice newly learned adaptive coping mechanisms is:
a. orientation b. working c. resolution d. termination
Many complementary therapies use sensory mechanisms to:
a. change the client's thinking and beliefs about illness and disability b. alter the client's emotions or level of consciousness toward a more calm, relaxed state c. increase the client's unconditional positive regard toward others d. energize the client to more aggressively fight the underlying disease or disability