A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report?
a. jaundice sclera
b. intestinal cramping
c. weakness and fatigue
d. weight loss
Ans: a. jaundice sclera
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During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a nursing diagnosis plan
What does this data represent? a. Symptoms b. Data clustering c. Signs of fluid overload d. Urinary retention
The nurse is caring for a client with hypertension. When planning care for this client, the nurse knows that blood pressure is influenced by all but which factor?
A) Pumping action of the heart B) Peripheral vascular resistance C) Heart rate D) Blood volume
A nurse is performing a spiritual assessment on a patient with depression. What does the nurse recognize as the key concept to a spiritual assessment?
1. Learn how the patient answers questions about his or her religion and how satisfied the patient is with those answers. 2. Learn how the patient answers questions about the meaning of life and how satisfied the patient is with those answers. 3. Assess how the patient answers questions about formal spiritual practices and how his or her symptoms interfere with these practices. 4. Assess how the patient answers a series of standardized questions that reveal the patient's choices of health care practices and religious choices.
A middle-aged male patient with usually well-controlled hypertension and diabetes visits the clinic. Today he has a blood pressure of 174/94 and a blood glucose level of 190 mg/dL
What additional patient information may indicate that an intervention by the nurse is needed? a. The patient indicates that he usually does blood glucose monitoring several times each day. b. The patient states that he usually takes his prescribed antihypertensive medications on a daily basis. c. The patient reports that he and his wife are getting divorced and are in a custody battle over their 12-year-old son. d. The patient states that the results are related to his family history because both of his parents have high blood pressure and diabetes.