Which of the following regarding the client history will assist the nurse in developing the plan of management? (Select all that apply.)
a. Provides direction for the rest of the assessment
b. Exposes key clinical manifestations
c. Aids in developing the plan of care
d. The degree of the client's distress determines the extent of the interview
e. Determines length of stay in the hospital setting
A, B, C, D
The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and precipitating events.
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A nursing student asks the faculty member to explain an oncogene. Which response by the faculty member is the most appropriate?
A. A cell that changes into a malignancy after environmental stress B. Any gene found inside a solid tumor that can be removed for biopsy C. A gene in a virus that encourages malignant transformation in cells D. An inherited gene that is programmed to become a malignant cell
The patient's ICP reading has gradually climbed from 15 to 23 mm Hg. The nurse's primary action is to
a. drain off 7 mm of CSF from the catheter. b. notify the physician. c. place the patient in a high Fowler position to decrease the pressure. d. check level of consciousness.
A nurse documents the following in a patient's medical record: "2/1/__, 1500. Patient appears weak and faint. Patient's skin is moist and cool, vomited bright red blood with clots
Health care provider notified and order received to give 2 u of packed red blood cells if stat Hgb is < 8.0. Pain medication will be given." This documentation meets which documentation principle? 1. Document objectively. 2. Do not document procedures in advance. 3. Use approved abbreviations. 4. Document changes in patient condition.
The term oliguria is used to describe:
a. an increased urine output > 2000 mL/day. b. a decreased urine output < 500 mL/day. c. a decreased urine output < 1000 mL/day. d. an increased urine output > 1000 mL/day.