Following an assessment of a patient, the nurse identifies the nursing diagnosis Activity Intolerance r/t Increased Weight Gain and Inactivity. The physician wants the patient to improve her endurance and increase activity. Which of the following is an outcome identified by the nurse?
A) Resting heart rate will be 90-100/minute
B) Blood pressure will be maintained between 140/80 and 160/90
C) Exercise will be performed 3 times per day over the next 2 weeks
D) Accommodation will be made for excess weight and fatigue
C) Exercise will be performed 3 times per day over the next 2 weeks
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The newborn delivered at term is being discharged. The parents are asking the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if the parent states:
1. "A quick cool bath will help wake up my son for feedings." 2. "I can check my son's temperature under his arm." 3. "My baby should be dressed warmly, with a hat." 4. "Cuddling my son will help to keep him warm."
An older patient with Alzheimer's disease has a feeding tube. The family wants to know if the patient will ever be able to eat solid food again. What information should the nurse include when responding to this family's question?
1. The dietitian will decide if this can be done. 2. It depends upon the patient's functional eating abilities. 3. This can be done but the feeding tube has to be removed first. 4. In the patient with dementia, the restoration of natural feeding is highly unlikely.
The nurse is meeting with a new mother for the first time during a home visit. The client delivered her first child 3 days ago. She had a normal pregnancy and a vaginal delivery. The infant is breastfeeding
Which statements by the mother indicate that she needs more information about the home visit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "You are going to check my baby's weight." 2. "You are going to watch me nurse the baby and give me tips." 3. "You are going to teach my mother about the baby." 4. "You are checking for safety issues when my son starts crawling." 5. "You are going to take blood samples from me and my son."
The nurse is admitting a client to the surgical unit. What statement by the nurse best reflects the nurse's assessment of the fifth vital sign?
A. "Do you have any concerns regarding your environment?" B. "Are you experiencing any discomfort right now?" C. "Is there anything I can do for you now?" D. "Do you have any complaints of pain?"