When assessing a patient with a possible MI, what should the nurse assess for? (Select all that apply.)
a. Pain radiating to left arm and jaw
b. Hypertension
c. Pallor
d. Diaphoresis
e. Erratic behavior
f.
Cardiac rhythm changes
ANS: B, C, D, E, F
Hypertension, vomiting, diaphoresis, hypotension, pallor, and cardiac rhythm changes are objective data seen in patients with an MI.
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A nurse is inspecting the ear canals and tympanic membranes of an 18-month-old child. How would the pinna be moved to achieve better visualization?
A) There is no need to move the pinna. B) Gently pull the pinna up and back. C) Gently pull the pinna down and back. D) Pull the pinna parallel to the side of the head.
The nurse has assessed a 16-year-old for cigarette smoking. The adolescent admits to smoking several times a day. A priority question to follow up with is:
1. How often does the patient cough? 2. How long has the patient been smoking? 3. How does the patient obtain the cigarettes? 4. How many other substances does the patient use?
Which activity is appropriate for a nurse engaged exclusively in community-based primary prevention?
a. Medication follow-up b. Teaching parenting skills c. Substance abuse counseling d. Making a referral for family therapy
When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is:
A) legal representation to care. B) conveying information. C) assisting in organization of care. D) noting the client's response to interventions.