A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain?

a. Average daily fluid intake
b. Neck circumference
c. Height and weight
d. Occupation and hobbies


ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment.

Nursing

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Mrs. Smith is admitted for treatment of depression with suicidal ideation triggered by marital discord. She had spoken with staff about her fears that the marriage will end, had indicated that she did not know how she could cope if her marriage ended, and has a history of suicide attempts when the marriage had seemed threatened in the past. Her spouse visits one night and informs Mrs. Smith that he has decided to file for divorce. Staff are aware of the visit and the husband's intentions regarding divorce but take no further action, feeling that the q15-minute suicide checks Mrs. Smith is already on are sufficient. Thirty minutes after the visit ends, staff make rounds and discover Mrs. Smith has hanged herself in her bathroom, using hospital pajamas she had tied together into a rope.

Which of the following statements best describes this situation? Select all that apply. 1. The nurses have created liability for themselves and their employer by failing in their duty to protect Mrs. Smith. 2. The nurses have breached their duty to reassess Mrs. Smith for increased suicide risk after her husband's visit. 3. Given Mrs. Smith's history, the nurses should have expected an increased risk of suicide after the husband's announcement. 4. The nurses correctly reasoned that suicides cannot always be prevented and did their best to keep Mrs. Smith safe via the q15-minute checks. 5. The nurses are subject to a tort of professional negligence for failing to prevent the suicide by increasing the suicide precautions in response to Mrs. Smith's increased risk. 6. Had the nurses restricted Mrs. Smith's movements or increased their checks on her, they would have been liable for false imprisonment and invasion of privacy, respectively.

Nursing

A patient with OCD tells the nurse, "Thinking these thoughts and doing all my rituals is beyond being silly

I have few friends and I know others laugh behind my back. I sometimes think I can control things, but I always find I can't. I don't know if I can continue to live this way." Which assessment question shows the nurse has an understanding of this patient's priority risk? a. "Are you feeling hopeless?" b. "Do you think you are socially isolated?" c. "Have you been thinking about hurting yourself?" d. "Do the rituals affect how you feel about yourself?"

Nursing

You are caring for a 21-year-old client who had a left orchiectomy for testicular cancer on the previous day. Which nursing activity will you delegate to an LPN/LVN?

A. educating the client about post-orchiectomy chemotherapy and radiation B. Administering the prescribed "as needed" (PRN) oxycodone (Roxicodone) to the client C. Teaching the client how to perform testicular self-examination on the remaining testicle D. Assessing the client's knowledge level about post-orchiectomy fertility

Nursing

Raymond, a patient with Zollinger-Ellison (ZE) syndrome, is administered a dose of 6 mg of cimetidine. How long will it take for peak absorption to occur?

A. 10 minutes B. Within 90 minutes C. 6 hours D. 2 to 3 hours

Nursing