A client presents to the primary care clinic and is disheveled in appearance, with stained, dirty clothing, body odor, and uncombed hair
Based on this observation, which of the following should the nurse assess during the history and physical exam? Standard Text: Select all that apply. 1. Occupation
2. Depression
3. Smoking history
4. Self-concept
5. Immunization status
1,2,4
Rationale 1: Occupation. The way a client dresses and maintains physical hygiene may provide clues to the client's occupation (perhaps the client has a physical job and has just come from work).
Rationale 2: Depression. The way a client dresses and maintains physical hygiene may provide clues to the state of the client's mental health.
Rationale 3: Smoking history. The client's disheveled appearance does not directly clue the nurse to explore the client's smoking history. Clues that would lead the nurse to fully explore the client's smoking history would include the smell of smoke on the client, the discoloration of the fingers from tobacco, hoarseness of the voice, and/or a cough.
Rationale 4: Self-concept. The way a client dresses and maintains physical hygiene may provide clues to the client's sense of self-esteem and body image.
Rationale 5: Immunization status. The observations made by the nurse do not clue the nurse to assess the client's immunization status.
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The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply
A) An elevated hematocrit level B) A low urine specific gravity C) Electrolyte imbalance D) Low protein level in the urine E) Absence of ketones in urine
The nurse explains to a family that it is not possible to determine the extent of a patient's burns after an accidental electrocution
What rationale does the nurse provide for this statement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Much of the damage done by electrical burns is beneath the surface. 2. The temperature of electrical energy can exceed 180°F. 3. The injury that is initiated by electrical energy does not stop when the current is interrupted. 4. The energy causing the burn affects rapidly dividing cells, which makes damage variable. 5. Electrical burns cause the same tissue response as alkali chemicals.
A nurse working with mentally ill patients recognizes which factor as having the greatest impact on a patient's tendency to seek treatment?
a. Social stigma b. Financial burden c. Lack of support services d. Ineffective family support
A recent nursing graduate has asked an expert nurse how best to foster her leadership abilities, since she wishes to explore leadership opportunities later in her career. How should the expert nurse best respond?
A) "Even if you don't trust a decision that you have to make, act like you chose the best option." B) "Become as specialized as possible in your nursing experience." C) "Develop your interpersonal skills by having a wide variety of interactions." D) "Become as assertive as you can and take every opportunity to guide the behavior of others."