Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider?
a. Generalized muscle aching
b. Sudden onset right flank pain
c. Janeway's lesions on the palms
d. Temperature 100.7° F (38.1° C)
ANS: B
Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE, but do not require any new interventions.
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The nurse caring for small-for-gestational-age (SGA) infants assesses them for attainment of outcomes related to nursing diagnoses. Which assessment finding best demonstrates attainment of priority outcomes?
A. Body temperature of 97.5 °F (36.4 ° C) B. Gains weight regularly C. Parents visit daily D. Skin remains intact
Which action by a nurse violates the rights of a psychiatric patient?
a. Arranging for a patient to work in the hospital kitchen for minimum wage b. Refusing to mail letters to the local newspaper written by a committed patient c. Placing the wristwatch of a patient with delusions in the hospital's main safe d. Discouraging a patient with paranoid delusions to sign a contract to sell a home
A nurse has a "cultural desire" to provide culturally competent care. Which of the following best illustrates an example of this?
1. The nurse relies on a textbook for information on an ethnic group. 2. The nurse brings in a translator to the clinic on a day that a lot of Spanish speak-ing people are expected. 3. The nurse takes Spanish classes in the evening at a local college. 4. A nurse judges others using his or her own cultural values.
The nurse is planning a presentation to the staff at a senior center. What factor that affects mental health in older adults should the nurse emphasize in the discussion?
1. Job loss 2. Divorce 3. Work stressors 4. Multiple losses