Determine Mrs. M's IBW and percent of IBW
5'3" = 100 + 3 × 5 = 115 + 10%
% IBW = actual body wt/IBW = 252/115 = 219%
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1. Behavior. 2. Respiratory rate. 3. Level of comfort. 4. Dietary habits.
In a nursing home, the nurse hears an unlicensed assistant threatening to withhold fresh water if the client does not do as the assistant instructed. What is the nurse?s priority action?
1. Immediately confront the assistant at the bedside about the behavior. 2. Ask the assistant to immediately follow you to a private place to talk. 3. Tell the nurse manager or nursing supervisor what was witnessed. 4. Encourage the client to report the situation to the administration.
A nurse is performing a complete oral exam on an elderly coherent cooperative client in the hospital. The nurse
A) includes palpation of the head and neck lymph nodes and assesses for tenderness and enlargement. B) does not need to wear gloves while examining the tongue including the posterior surface. C) assures the client not to be concerned with white patches that occur on the surface of the oral mucosa. D) knows that halitosis is considered normal.
A client asks the nurse why there is "waxy yellow stuff" on the cotton swab when he cleans his ears. Which is the nurse's best response?
a. "The yellow ear wax helps transmit sound to your middle ear." b. "The yellow ear wax indicates that you have an infection in your ears." c. "The yellow ear wax helps protect and lubricate the inside of your ear canal." d. "The yellow ear wax builds up when you don't clean your ears often enough."