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A nurse is doing an admission assessment on a client who has multiple bruises on her body. The nurse suspects abuse. Which of the following statements is the most appropriate for the nurse to ask? Are you being hurt by your partner? Are you happy with your home environment? Do you and your partner have problems resolving personal conflict Do you feel afraid when your partner is around ? - CORRECT ANSWER-d" Great job! Abuse is defined as the intentional infliction of injury, mental or physical or intentional neglect of care. A direct question is needed to assess if this is happening.
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A nurse is doing an admission assessment on a client who has multiple bruises on her body. The nurse suspects abuse. Which of the following statements is the most appropriate for the nurse to ask? Are you being hurt by your partner? Are you happy with your home environment? Do you and your partner have problems resolving personal conflict Do you feel afraid when your partner is around? - CORRECT ANSWER-d" Great job! Abuse is defined as the intentional infliction of injury, mental or physical or intentional neglect of care. A direct question is needed to assess if this is happening. A nurse is caring for a client who has suspected internal bleeding. A nurse is aware the signs of clotting and bleeding concurrently indicate: Hemophilia Polycythemia Vera Dismesnated Itnravular cogultion - CORRECT ANSWER-Great job! Disseminated intravascular coagulation (DIC) is a rare, life-threatening condition that prevents blood from clotting normally. The blood clots reduce blood flow and can block blood from reaching bodily organs. This increased clotting can use up the blood's platelets and clotting factors. Fewer platelets and clotting factors available result in excessive bleeding. Hemophilia A, also called factor VIII (FVIII) is a genetic disorder caused by missing or defective factor VIII, a clotting protein so blood does not clot properly. Polycythemia vera is a disorder of the bone marrow. It mainly causes too many red blood cells to be produced. A nurse is caring for a client with peripheral vascular disease and notices the legs are cold and blue. Which is the priority action for the nurse to take? Notify the doctor Assess for distal pulses Adminster epinephrine chart the obstervation - CORRECT ANSWER-a. That is incorrect. Peripheral vascular disease typically strikes the veins and arteries that supply the arms, legs, and a client's leg looks pale or blue; the leg becomes cold; a nurse should check the pulses before notifying the physician. The presence of a pulse will need to be given to the physician.
While assessing a client newly diagnosed with rheumatoid arthritis, the nurse should focus the assessment on the severity of: Rheumatoid nodules Stiffnes of joints when wakng up in the morning Range of motion limitations defomred joints of hand - CORRECT ANSWER-Great job! Clients with rheumatoid arthritis, including those in the early stages, often experience early morning stiffness in their joints. Other signs and symptoms listed appear in more advanced stages of rheumatoid arthritis. A nurse is bringing a client back to the operating room for an appendectomy and finds there is no consent form in the chart. What is the initial action by the nurse? Contact the unit superivisor Notify the healthcare provider File an incidient report Bring the client back to the surgical unit - CORRECT ANSWER-b: Great job! Notify the doctor perhaps the client stated he did not want to sign a document but wanted the surgery. At times the clients are able to give an implied consent by showing up for surgery the day scheduled. As a new nurse the safest thing to do is to notify the physician. The nurse is caring for a client who has a new colostomy. The colostomy stoma is red, moist and slightly raised. The nurse should: Document the finding as normal reinforce the dressing Determine if the client is having an allergic reaction apply a barrier paste to the stoma - CORRECT ANSWER-A A client has just been told they have terminal cancer and is crying. What is the initial response by the nurse? Ask the client what are her concerns? Sit there quietly Contact a social worker Educate the client on hospice procedures - CORRECT ANSWER-Great job! The nurse should offer herself to the client by being present and sit in silence. This is the most therapeutic response. b A client on a ventilator is diagnosed with stage 4 lung cancer. The nurse enters the room and the client's high pressure alarm is sounding. The nurse knows the cause of this alarm is which of the following?