The nurse is assessing an older patient diagnosed with heart failure several years ago. Which would indicate the patient is in the late stage of heart failure?
1. Fatigue
2. Confusion
3. Lung congestion
4. Shortness of breath
2. Confusion
Explanation: 1. Most early heart failure symptoms include fatigue and tiredness.
2. When the patient becomes mentally confused, that presents during later stages of heart failure.
3. Most early heart failure symptoms include congestion in the lungs.
4. Most early heart failure symptoms include breathlessness or dyspnea.
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Which reference citation indicates a secondary source?
1. Short, S., Hall, C., Engel, S., & Nigel, C. (2004). Exercise imagery and the stages of change. Journal of Mental Imagery, 28(1,2), 61–78. 2. Jansen, C. E., Miaskowski, C., Dodd, J. S., & Dowling, G. (2005). Chemotherapy-induced cognitive impairment in women with breast cancer: A critique of the literature. Oncology Nursing Forum, 32(2), 329–342. 3. Miaskowski, C. J. (2000). Improving pain management: An ongoing journey. Oncology Nursing Forum, 27(6), 938–944. 4. Loegering, L., Reiter, R., & Gambone, J. (1994). Measuring the quality of health care. Clinical Obstetrics & Gynecology, 37(1), 122–136.
The nurse is planning instructions to address home safety with an older patient. What should be included in this teaching? (Select all that apply.)
A) Install handrails on both sides of all stairways. B) Use nightlights along stairways and walkways. C) Secure rugs with adhesive tape. D) Wear socks when walking around the home. E) Install grab bars in the bathtub.
A client had an epidural inserted 2 hours ago. It is functioning well, the client is stable, and labor is progressing
Which parts of the nurse's assessment have the highest priority? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess blood pressure every hour. 2. Assess the pulse rate every hour. 3. Palpate the bladder. 4. Auscultate the lungs. 5. Assess the reflexes.
Which of the following substances is the predominant component of extracellular fluid?
a. saline c. proteins b. potassium d. phosphate