The nurse is at the home of a postpartum patient for an initial assessment. The patient gave birth by cesarean section 1 week earlier
Which statements should the nurse include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Because you had a cesarean, I'd like to assess your incision."
2. "You aren't having any problems nursing, right?"
3. "How rested do you feel since you came home?"
4. "Since you are bottle-feeding, I won't assess your breasts."
5. "You should remain at home for the first 3 weeks after delivery."
1,3
Rationale 1: The homecare nurse should assess the cesarean incision.
Rationale 2: Therapeutic communication prohibits asking leading questions.
Rationale 3: The homecare nurse should assess the mother's level of rest/sleep and fatigue. New mothers should be instructed to match their activities to their energy level.
Rationale 4: Breasts should be assessed for engorgement even for bottle-feeding mothers.
Rationale 5: New mothers should be instructed to match their activities to their energy level.
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After an assessment, the nurse suspects a client with multiple injuries is a victim of domestic violence. Which action should occur next?
A) Conducting a team assessment B) Medicating for anxiety as prescribed C) Notifying the police D) Treating the injuries
The nurse has assessed the hospitalized client. The nurse is preparing to document the findings using APIE. Rank the following findings in the proper order of documentation
Standard Text: Click and drag the options below to move them up or down. 1. The client states upon admission, "I don't know what's wrong with me, but I can't see out of my left eye and I can't stand up by myself.". 2. The client is unable to move from the bed to the chair without the assistance of two nurses. The client is unable to eat without assistance. 3. The healthcare provider writes an order for the nurse to administer heparin. 4. On the morning of the client's discharge from the hospital, the client has been able to ambulate 50 feet with a walker.
Which of the following would be the nurse's primary goal during the first visit to home-bound clients?
a. To assess the health of all family members and the immediate environment b. To discuss the time and financial limits to the care the nurse can give c. To establish rapport with the clients and work with them to define mutually agreeable goals d. To implement the nursing care plan established before hospital discharge
The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client's musculoskeletal system? Select all that apply
A) Joint stiffness B) Rhinorrhea C) Shortness of breath D) Chest pain E) Muscle strength F) Swelling