You observe increased hair growth across the face and chest of a female client. What is your next best action?
A. Notify the physician.
B. Document the finding as the only action.
C. Assess for changes in fat distribution and capillary fragility.
D. Suggest that the client may wish to shave this embarrassing hair growth.
C
Increased hair growth on the face and chest of a female client, hirsutism, is one manifestation of hormonal imbalance. The nurse looks for additional associated changes in fat distribution and capillary fragility (Cushing's syndrome) or clitoral enlargement and deepening of the voice (possible ovarian dysfunction).
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A client is diagnosed with a respiratory health problem. What should the nurse consider when determining interventions for this client's care? (Select all that apply.)
1. Assist the client to perform the intervention. 2. Monitor the client for potential complications. 3. Ensure outcomes are time specific and measurable. 4. Supervise the family while performing the intervention. 5. Delegate the intervention to be completed by another caregiver.
Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans:
1) Apply to every patient on a particular unit. 2) Include both medical and nursing orders. 3) Specify patient outcomes for each day. 4) Help ensure that important interventions are not overlooked.
A client is experiencing an overdosage of heparin. The nurse would expect to administer which of the following?
A) Vitamin K1 B) Protamine C) Ticlopidine D) Tenecteplase
The nurse is caring for an Asian American client who is in the hospital for chemotherapy via central line. The nurse plans to check this client frequently for signs of impending sepsis because Asian clients:
1. Are more prone to sepsis. 2. Are poorly nourished. 3. Perceive reporting symptoms as complaining. 4. Do not respond well to chemotherapy.