During the morning assessment of an 85-year-old female client, the nurse determines the client has 21 pitting edema of the lower extremities. Later, the client describes a sudden onset of breathlessness and refuses to go to physical therapy
The client denies pain. Which of the following nursing interventions is most appropriate for the client at this time?
A) measuring intake and output.
B) daily weights.
C) contacting the client's physician for further evaluation and treatment.
D) allowing the client to rest.
C
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When assessing a patient's abdomen, the nurse recognizes the importance of reserving palpation as the last technique. What rationale would the nurse provide for this sequence?
1. Early palpation may result in rebound pain. 2. The technique is likely to increase the patient's level of anxiety. 3. Most patients do not like being touched. 4. The pressure of palpation can interfere with hearing bowel sounds.
An intoxicated client was brought to the hospital at 2 a.m. following a fall that resulted in a fractured femur. If the client is going to experience withdrawal symptoms, the nurse should be alert for them to peak around which time?
A) 54-72 hours after drinking stops B) 6-12 hours after drinking stops C) 24-48 hours after drinking stops D) 72-92 hours after drinking stops
A nurse is caring for a client with cluster headaches. The nurse knows that cluster
headaches result from vascular disturbance leading to vasodilation. What symptom and sign of vasodilation should the nurse look for in the client? A) Tears forming B) Reduced respiratory rate C) Generalized shivering D) Shrunken eyes
A forensic nurse may assist in the scientific investigation of what?
A) A nurse whose practice does not meet established standards B) An outbreak of a nosocomial (hospital-acquired) infection that may have resulted from inadequate infection-control practices C) A death that is the result of a criminal act D) Incident reports involving falls causing injury