The home health nurse is caring for a patient with congestive heart failure (CHF). Which assessment finding should the nurse report immediately to the physician?
a. Moderate shortness of breath after walk-ing down the hall
b. A 3 pound weight gain over the course of a week
c. Heart rate of 104 beats/min after ambu-lating to the bathroom
d. Increase in urinary output to 50 mL in the last hour
B
A weight gain without an increase in caloric intake is indicative of fluid retention, which is an indication of worsening heart failure. Moderate shortness of breath after exercise and a mild in-crease in heart rate after activity are expected. A decrease in urinary output would be of concern.
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The nurse can expect the parent of a child with mal ojo (evil eye) to believe that the effects of the spell can be broken after
a. ignoring the child. b. feeding the child warm foods. c. looking deeply into the child's eyes. d. a root doctor or native healer intervenes.
Before entering a person's room, you should:
a. Get the person's attention b. Knock on the door and wait to be asked in c. Check to see if the person has visitors d. Check to see if the person is in the bath-room
Incomprehensible language is characteristic of persons with schizophrenia. A client is telling you about his hallucinations of Indians on the wind calling out to him "ipeechee
" You offer the client a drink of water, and the client says, "Emanah". You wonder about these words, which seem created by the client. If in your assessment you discover that the client makes up these words, they are good examples of which of the following? a. incoherence b. neologisms c. tangentiality d. word salad
What are symptoms that may indicate an inguinal hernia?
1. Right lower quadrant pain with rebound tenderness 2. A feeling of weakness or pressure in the groin 3. The lack of a hydrocele in a newborn 4. Pain after internal rotation of a flexed thigh