The nurse is assessing the client's cardiovascular system. The nurse is preparing to assess the client for the presence of a lift or heave
Which of the following directions should the nurse provide for the client? Standard Text: Select all that apply. 1. "I am going to put you into a position where your feet are actually above your head.".
2. "I need you to turn to your left side.".
3. "Can you please turn onto your stomach?"
4. "I need you to sit up straight.".
5. "I am going to elevate your head to a 30-degree angle while you lie on your back.".
4,5
Rationale 1: "I am going to put you into a position where your feet are actually above your head.". The client should not be placed into Trendelenburg position to assess for heaves or lifts.
Rationale 2: "I need you to turn to your left side.". The client does not need to turn to the left side to evaluate the presence of heaves or lifts.
Rationale 3: "Can you please turn onto your stomach?" The nurse should not evaluate the client's chest for the presence of heaves or lifts while the client is in a prone position.
Rationale 4: "I need you to sit up straight.". The nurse should inspect the client's chest for heaves or lifts while the client is sitting upright.
Rationale 5: "I am going to elevate your head to a 30 degree angle while you lie on your back.". The nurse should inspect the client's chest for heaves or lifts while the client is in a semi-fowler position with the head of bed at 30 degrees.
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A group of nurses at the managed behavioral health organization have the task of revising the
current admission criteria. 1 . Clear risk of client danger to self or others 2 . Dangerous decompensation of a client under long-term treatment 3 . Failure of community-based treatment demonstrating clear need for intensive, structured treatment 4 . Medical need unassociated with psychiatric treatment or associated with treatment 5 . Provision of respite for caregivers Which, if any, of the criteria should be deleted? A. none B. 1 C. 2 D. 3 E. 4 F. 5
The nurse is performing a mental status examination when caring for a patient with a neurocognitive disorder (NCD). The patient's spouse asks why a mental status examination is necessary. How will the nurse respond?
1. "The mental status exam is the only way to assess the cognitive decline of a patient with early stage Alzheimer disease." 2. "The mental status exam is used to assess depression in a patient with early stage Alzheimer disease." 3. "The mental status exam will reveal slow and progressive cognitive decline of a patient with early stage Alzheimer disease." 4. "The status exam will reveal rapid and dramatic changes in cognition of a patient with early stage Alzheimer disease."
Musculoskeletal health is especially enhanced by a diet containing recommended amounts of
a. protein, calcium, vitamin D, and phosphorous. b. carbohydrates, calcium, vitamin D, and potassium. c. fiber, iron, vitamin D, and sodium. d. whole grains, calcium, magnesium, and vitamin D.
A client with an upper respiratory tract infection was prescribed roxithromycin, an
antibiotic. What should the nurse tell the client that irregular administration of this medication could lead to? A) Decreased absorption of the drug B) Development of drug resistance C) Increased rate of elimination of the drug D) Increased chances of serious adverse events