The nurse needs to assess the client's elimination patterns. Which of the following clients will most likely deny the urge to defecate?
A) Client with anxiety and depression
B) Client who consumes >30 g of fiber
C) Client who has a colostomy
D) Client 3 days' post-vaginal delivery
Ans: D
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When assessing the client with dramatic weight loss or gain, the nurse should consider:
1. The focus of the assessment must be on the psychological findings. 2. There is usually a direct cause and effect. 3. The focus of the assessment must be on the physical findings. 4. Both can be caused by physical or mental conditions.
A patient has sought care, stating that she developed hives overnight. The nurse's inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?
A) Type I B) Type II C) Type III D) Type IV
A client with allergic rhinitis is prescribed an antihistamine. The nurse instructs the client to suck on sugarless hard candy to address which of the following?
A) Drowsiness and sedation B) Thickening of the bronchial secretions C) Altered sensation of taste D) Dryness of the oral mucosa and the throat
The nurse wants to assess consciousness, agitation, anxiety, sleep, and ventilatory synchrony in a client with a traumatic brain injury. Which scale should the nurse use for this assessment?
1. Ramsay Sedation 2. Riker Sedation-Agitation 3. AACN Sedation Assessment 4. Richmond Agitation-Sedation