When completing the assessment of an immobilized patient, the most likely place for the nurse to assess edema includes which of the following? Select all that apply
A. Face
B. Feet
C. Sacrum
D. Abdomen
B, C
Edema indicates the heart's inability to handle an increased workload. Fluid moves to dependent body regions including sacrum, legs, feet, and hips.
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An older adult female has been given instructions concerning an endocrine assessment the nurse will be conducting. Which statement by the patient would indicate that further instruction is necessary?
1. "Because I am already past menopause, there will be no need for a breast exam in this assessment.". 2. "The nurse will look at my skin, nails, and hair." 3. "I'll be sure to let the nurse know that diabetes runs in my family." 4. "The nurse will palpate my throat in the front."
The older person's ability to sense pain is:
a. Increased b. Decreased c. The same as a younger adult's d. The same as a young child's
The nurse is assessing a client with a history of rheumatic fever. Subjective findings include fatigue and objective findings include a diastolic murmur in the apical area when the client is in the left lateral position. Which diagnosis should the nurse suspect?
A. Tricuspid regurgitation. B. Mitral regurgitation. C. Pulmonic stenosis. D. Mitral stenosis.
The most appropriate method to use to assess for a carotid artery for the presence of a bruit is to:
1. Palpate each artery lightly; first the right side and then the left 2. Have the client turn the head toward the side being auscultated 3. Place the bell of the stethoscope over artery near outer edge of the clavicle 4. Have the client hold the breath while auscultating with the stethoscope bell