The nurse is collecting data from a patient with a stoma. What should the nurse document for a health stoma?
a. Gray and dry
b. Black and dry
c. Bluish and wet
d. Pink and moist
ANS: D
The stoma should be pink to red, moist, and well attached to the surrounding skin. A. C. A bluish or gray stoma indicates inadequate blood supply. B. A black stoma indicates necrosis.
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The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate?
a. The patient is asked to assume a prone position. b. The patient is asked to bend his or her knees to the side in a froglike position. c. The nurse firmly presses against the bone with the patient in a semi-Fowler position. d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.
Nurse B talks with Patient G about effective methods of managing stress incontinence. What role of the gerontological nurse is being enacted in this exchange?
A) Innovator B) Caregiver C) Educator D) Advocate
A client approaches the nurse and blurts out "You've got to help me! Something terrible is
happening. I'm falling apart. I can't think. My heart is pounding and my head is throbbing.". The nurse responds "It's almost time for visiting hours. Let's get your hair combed.". This interaction can be evaluated as a. a distracting technique to lower anxiety. b. bringing up an irrelevant topic. c. sensitive to physical needs. d. addressing false cognitions.
Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral insufficiency?
A) Split B) Diminished C) Accentuated D) Varying