The nurse assesses a friction rub in a patient who is 2 days post–myocardial infarction (MI). The nurse recognizes this finding indicates which problem?
a. A recurrent MI
b. Pleural effusion
c. Pericarditis
d. Angina
C
Friction rubs occur in pericarditis when the inflamed area of the infarct rubs the pericardium.
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An African American client who is highly suspicious is given to angry outbursts and accusations
that staff are discriminating against him when they remove possibly harmful objects from his possession according to hospital policy. An explanation that shows cultural awareness relating to the client's behavior is that it may be prompted by a. feelings of powerlessness. b. institutional discrimination. c. fear of abandonment. d. family solidarity.
After ingesting a large amount of narcotics, a client has a respiratory rate of 8 per minute. Which acid-base disturbance is the client at risk for developing?
1. Respiratory acidosis 3. Metabolic acidosis 2. Respiratory alkalosis 4. Metabolic alkalosis
An otherwise healthy older adult reports having begun to experience problems, "holding my water." The nurse shows an understanding of interventions that may help minimize the problem of urinary incontinency when: Select all that apply
a. asking whether the client smokes tobacco b. assessing the average amount of caffeine the client drinks daily c. asking if the client has been evaluated for diabetes recently d. suggesting the client keep a record of the amount of fluids ingested daily e. reviewing the client's current medication list
A nurse from the ICU receives report from the ED nurse on a patient that includes a diagnosis of syncope unknown etiology
Orthostatic VS lying: 110/80 mm/Hg; sitting: 100/74 mm/Hg; standing: 92/40 mm/Hg. Based on this information, the nurse should monitor the patient's a. breathing. b. dietary intake. c. peripheral pulses. d. activity.