The nurse is caring for a client who has long-standing chronic obstructive pulmonary disease (COPD) and is recovering from a stroke. Which intervention is a priority when activity tolerance is assessed during rehabilitation?
a. Assess vital signs before, during, and after activity.
b. Perform a daily cognitive assessment.
c. Consult physical therapy to ambulate the client.
d. Monitor the client's progress in self-care ability.
A
To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase over 20 mm Hg, and vital signs will not return to baseline within 5 minutes after the activity. A cognitive assessment is not necessary before basic activities are performed. A consultation would not provide data on activity tolerance, and monitoring of self-care ability does not directly reflect tolerance as vital signs do.
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1. Acute glaucoma 2. Blepharitis 3. Periorbital edema 4. Anisocoria
The nurse is assessing a newly admitted client's current medication. Which of the following is an example of objective data?
A. The client's wife tells the nurse what medications the client has been receiving. B. The nurse checks the prescription bottles the client has brought to the hospital. C. The nurse asks the healthcare provider what medications the client was currently taking. D. The client lists the medications that have been prescribed.
An important factor to consider in pressure ulcer prevention and healing is
A. nutrition. B. medication. C. use of adaptive devices. D. massage.
Which statement made by a patient indicates a need for further discharge instruction about baclofen [Lioresal]?
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