What priority assessment data should be shared with the interdisciplinary team from a client admitted to the emergency department with a lacerated artery?
a. Information regarding next of kin to notify in case the client dies
b. History about what medications the client is currently taking
c. Measurement of blood pressure and pulse
d. Assessment of rate and depth of respirations
C
In establishing an emergency database, assessment first focuses on the immediate problem, especially with a high probability for a life-threatening consequence. Assessing vital signs such as blood pressure and pulse, which indicate the client's hemodynamic status, is the priority intervention. Determining the client's current medications, notifying next of kin, or measuring the rate and depth of respirations is of less importance at this time.
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On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with the client?
A. "You certainly look stressed. Can you tell me about the upsetting events that have occurred in your life recently?" B. "Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?" C. "You're having very frightening thoughts. I'll help you find ways to cope with this scary thinking." D. "Hello, ___. I'm going to be caring for you while I'm on duty. You look very frightened, but I'm sure you'll feel better by tomorrow."
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A) Tertiary prevention B) Secondary prevention C) Primary prevention D) Disease prevention
A male client comes to the emergency department complaining of nocturia and nonspecific fullness in the lower pelvic region. What is the best assessment question for the nurse to ask the client?
1. "Are you constipated?" 2. "Are you sexually active?" 3. "How old are you?" 4. "Do you take daily showers?"