A patient scored 350 on the Holmes and Rahe Social Readjustment Rating Scale and is not demonstrating any physical or emotional signs of illness. The nurse realizes it is also important to assess:
1. Age, perception, and previous experiences.
2. Education level.
3. Employment status.
4. Nutritional status.
Age, perception, and previous experiences.
Rationale: Even though it was previously theorized that the greater the number of stressful life events occurring throughout a specific period of time, the greater the vulnerability to illness, the relationships can often be weak, as evidenced by this patient's lack of physical or emotional illness. When this occurs, the nurse should assess additional factors such as age, perception, health, and previous experiences when considering life events as stressful. Educational level, employment status, and nutritional status are not typically assessed when trying to determine if an event is stressful to a patient.
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A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.)
a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations.
The nurse encounters a woman giving birth at the local mall. What should the nurse do first?
1. Apply counterpressure to the perineum. 2. Ask a bystander for a dry piece of clothing. 3. Visualize the perineum. 4. Determine if the membranes have ruptured.
When examining a patient for pulsus paradoxus, the nurse would do which of the following? Select all that apply
a. Place the patient in a supine position. Instruct the patient to breathe normally. b. Apply the blood pressure cuff. c. Inflate the cuff to 40 mm Hg above the patient's last systolic blood pressure reading. d. Slowly deflate the cuff until the first systolic sound is heard. e. Observe the patient's respirations because the systolic sound may disappear during normal inspiration. f. Quickly deflate the cuff again and note the point at which the dyastolic sound is heard.
The nursing is caring for a client who will be having artificial implants for breast reconstruction. The client is arriving at the physician's office for which procedure completed before the surgery can be done?
A) Incisional alignment B) Tissue expansion C) Fluid drainage D) Pain control