Which finding on cardiovascular assessment of an older adult client would warrant further evaluation?
a. Occasional ectopic beats heard on auscultation of the heart
b. Murmur heard over the mitral valve
c. Systolic pressure of 156 in the right arm and 188 in the left arm
d. Persistent S4 sound in a client with a history of decreased ventricular function
ANS: C
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A) 6 deciduous and 12 permanent teeth. B) 12 deciduous teeth. C) 16 deciduous and 2 permanent teeth. D) 20 deciduous teeth.
How should the nurse document the white thick coating on the infant at delivery?
A) Lanugo B) Milia C) Vernix D) Amniotic fluid
Nurse working the night shift understands the importance of enhancing the sleep patterns of his patients. In order to do so, he should
A) Only wake them for the 12:00 AM and 4:00 AM vital signs B) Allow the patient time to sit at the desk to enhance better rest C) Evaluate the sleep response of the patient with a polysomnogram D) Cluster activities to allow 90 to 120 minutes of sleep
The nurse assesses these symptoms in a client with bacterial pneumonia: chills, elevated temperature, tachypnea, productive cough of yellow sputum, shortness of breath, and fatigue. Based on the assessment data, what is the most appropriate nursing diagnosis (ND) for this client?
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