Which of the following increases the patient's risk of falls?
A. Adequate lighting when the patient is out of bed
B. Keeping the bed in a low position
C. Sink next to the toilet
D. Confused mental status
Answer: D
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The nurse working in the ICU knows that chronic elevation of left ventricular end-diastolic pressure will result in the patient displaying which of the following clinical manifestations?
A) Chest pain and intermittent ventricular tachycardia B) Dyspnea and crackles in bilateral lung bases C) Petechia and spontaneous bleeding D) Muscle cramping and cyanosis in the feet
A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? Select all that apply
A) Perforation into the mediastinum B) Development of an esophageal lesion C) Erosion into the great vessels D) Painful swallowing E) Obstruction of the esophagus
The nurse is beginning a health history with a 3-year-old child. Which question should the nurse ask the mother first when beginning the history?
A) "Is Sarah ill in any way?" B) "Tell me about your daughter.". C) "Has Sarah been ill in the past?" D) "Do you have any concerns about Sarah?"
The client reports following the "food pyramid" to guide nutritional intake. How should the nurse evaluate this information?
A) Since this food pyramid is produced by the U.S. Department of Agriculture, the client is likely consuming necessary levels of all essential nutrients. B) Following the appropriate food pyramid is helpful, but there are additional factors to consider in a balanced diet. C) The food pyramid is most useful when applied to the nutritional intake of children. D) The food pyramid is not very useful, because it does not take fluid intake and combination foods into consideration.