The nurse is attempting to detect a pericardial friction rub on a patient. Which actions will help the nurse in gathering this data during auscultation? (Select all that apply.)
a. Have the patient sit up.
b. Have the patient lie flat.
c. Have the patient lean forward.
d. Listen to the posterior of the chest.
e. Instruct patient to hold breath as listening.
f. Have the patient deep breathe as listening.
ANS: A, C
The nurse should have the patient sit up and lean forward to bring the heart closer to the chest wall. B. D. E. F These actions will not improve the nurse's ability to detect a pericardial friction rub.
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The nurse is participating in psychological debriefing of a patient who is experiencing a crisis. Which statements will the nurse include when providing education to the patient or family of the patient who is experiencing crisis? Select all that apply
1. "Transportation is available if you cannot drive." 2. "You may want to use a calendar to help you track your response to the crisis." 3. "Do you have a spiritual leader that you would like me to contact for you?" 4. "The sedative that the health care provider prescribed is a common treatment." 5. "The relaxation techniques that the health care provider suggested are a common treatment."
A 13-month-old child is having a dressing changed on a packed leg wound. Which action from the parents should be encouraged by the nurse during the treatment?
A) Encourage the father to talk quietly to the child. B) Make sure the father is sitting on a chair near the door. C) Ask the father to wait outside until the treatment is complete. D) Have the father hold the child's legs still during the treatment.
Milieu therapy is a therapeutic application for people with personality disorders in which the therapy is based on: (Select all that apply.)
a. maintaining a structured environment. b. participating as a member of the structured environment. c. practicing appropriate social behavior. d. actively attempting to modify behavior. e. learning to modify feelings and emotional responses.
The nurse is caring for a client who will be going home after a radical jaw and neck resection. The client's spouse will be the primary caregiver at home and will need to care for the client's feeding tube and tracheostomy
Which skill is the highest priority for the nurse to teach the client's spouse before discharge from the hospital? a. Monitoring the incision lines for infection or leakage of saliva b. Assessing the client for readiness to resume oral feedings c. Cleaning the tracheostomy and suctioning as needed d. Administering tube feedings and cleaning the feeding tube site