The nurse is performing a physical assessment on an elderly client. The nurse evaluates the muscular skeletal system, understanding that the following might be typical in the geriatric client: Standard Text: Select all that apply
1. Elderly clients have decreased ROM.
2. Elderly clients have decreased subcutaneous fat that can affect their ability to stay warm.
3. Vigorous assessment techniques such as hopping on one foot are appropriate.
4. Evaluation of the ability to carry out ADLs can indicate a deviation from normal in the musculoskeletal system assessment.
5. Warmth in one or more joints.
1,4
Rationale: Elderly clients can have decreased ROM.
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A client of the Roman Catholic religion has given birth to a premature baby with very serious respiratory difficulties. Based on the client's religion, it is important for the nurse to understand that the client may:
a. want the infant to be baptized because its life is in danger. b. be opposed to blood transfusions. c. want to receive Holy Communion for herself as soon as possible. d. require that the body part or tissues (such as the placenta) be buried.
A nurse makes clinical judgments based upon trial and error and past clinical experiences. Which of the following problems can result from using these data sources in clinical decision making?
a. Not all sources of information are reliable. b. Authority always leads to faulty decision making. c. Ethical knowledge is not taken into ac-count. d. Trial and error has led to poor outcomes.
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. Why is this done?
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