A 68-year-old patient is admitted to the critical care unit with reports of midchest pressure radiating into the jaw and shortness of breath when walking up stairs
The patient is admitted with a diagnosis of "rule out myocardial infarction." The history portion of the assessment should be guided by
a. medical history.
b. history of prior surgeries.
c. presenting symptoms.
d. a review of systems.
C
For a patient in acute distress, the history taking is shortened to just a few questions about the patient's chief complaint, precipitating events, and current medications. For a patient who is not in obvious distress, the history focuses on the following four areas: review of the patient's present illness; overview of the patient's general cardiovascular status; review of the patient's general health status, including family history of coronary artery disease (CAD), hypertension, diabetes, peripheral arterial disease, or stroke; and survey of the patient's lifestyle, including risk factors for CAD.
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The admitting note describes a patient with depression as having anergia and anhedonia. The nurse should plan measures to: (Select all that apply.)
a. channel excessive energy. b. reduce guilty ruminations. c. counter psychomotor retardation. d. instill a sense of hopefulness. e. reduce stimulation. f. promote physical activity.
During the physical examination of a client, the nurse notices the color of urine turn pale blue-green. The nurse, therefore, asks about the drugs that the client may have taken
Why is it important to know what drugs the client may have taken earlier? A) Because drugs may affect the outcome of urinary tract tests B) Because drugs may affect the size of the urinary bladder C) Because drugs may affect urine characteristics D) Because drugs may affect the amount of urine produced
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
a. Completes a comprehensive database b. Identifies pertinent nursing diagnoses c. Intervenes based on priorities of patient care d. Determines whether outcomes have been achieved
The nurse is completing preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first?
1. Apply an allergy bracelet on the client's wrist 2. Label the client's allergies on the front of the chair 3. Ask the client what happens when he takes codeine 4. Document the allergy on the medication administration record