A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease. The client always remains in a sitting position to help him breathe more easily
Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client?
A) Back of the skull
B) Elbows
C) Sacrum
D) Heels
Ans: C
The sacrum bears the greatest pressure during a sitting position. The back of the skull, elbows, and heels bear pressure in a supine position.
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A client presents at the emergency department reporting a burning pain in the chest of a 7 on a 0 to 10 pain scale. Gastroesphogeal reflux disorder (GERD) secondary to hiatal hernia is diagnosed. Based on this data, which is the priority nursing diagnosis
A) Dysfunctional Gastrointestinal Motility B) Anxiety C) Acute Pain D) Ineffective Health Maintenance
A nurse is caring for a patient with a pulmonary artery catheter who has been diagnosed with pulmonary hypertension. The nurse knows that pulmonary hypertension is related to which of the following rheumatic diseases?
A) Fibromyalgia B) Gout C) Scleroderma D) Systemic lupus erythematosus
Who or what is the primary source of information for a nursing history?
A) previous medical records C) the patient B) other healthcare personnel D) family members
The nurse performing eye irrigation would: a. have the individual tip their head up and run theirrigation fluid over the open eye
b. direct the irrigating fluid from the nasal corneroutwards. c. have the individual look straight ahead. d. tilt the head away from the affected side.