Which assessment finding will alert the nurse to a worsening of the client's hyponatremia?
A. The client is anxious and combative.
B. Diastolic blood pressure has increased by 8 mm Hg.
C. Bowel sounds are hyperactive in all abdominal quadrants.
D. Deep tendon reflexes have changed from 1+ to 2+.
Answer: C. Bowel sounds are hyperactive in all abdominal quadrants.
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A nursing strategy that makes limit setting better accepted by clients with personality disorders is to
first a. confront the client with the inappropriateness of the behavior. b. explore with the client the underlying dynamics of the behavior. c. reflect back to the client an understanding of the client's distress. d. state a value judgment regarding the behavior and its consequences.
A nurse is caring for a postoperative patient who has had spinal anesthesia. Which assessment is a priority for this patient?
a. Complaints of a headache b. Pulse rate of 78 beats/min c. Voided 300 mL d. Blood pressure of 126/78 mm Hg
The nurse has obtained supplies to change a complex abdominal dressing on a postoperative client. When the nurse arrives at the room, the client is praying with family. What action should be taken by the nurse?
A) Quietly shut the door and wait in the hall until asked to enter. B) Come to the bedside and join in with the prayer. C) Stand quietly just inside the room door until the prayer is completed. D) Politely ask the client to allow the dressing change to proceed.
An assessment finding example for caregiver strain would be which of the following?
a. Caregiver routinely creates a weekly menu plan. b. Caregiver has not received medical care when ill. c. Caregiver can identify respite care provider. d. Caregiver attends religious service.