A nurse is assessing an adult client who has been immobile

A nurse is assessing an adult client who has been immobile. The nurse notes that the client is withdrawn, confused and at times physically immobile. Drug adverse effects D. , 2019). " d. Crackles in the lungs E. Nurses are responsible for identifying, managing, and eliminating potential fall hazards for clients. What should the nurse do first? a. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?, A nurse is caring for a PT who requires 24-hour urine collection. A nurse is using the Banner Mobility Assessment Tool (BMAT) to determine a client’s level of mobility while in the long-term care center. Which of the following heart sounds should the An older adult client is reporting dry, itching skin. The nurse should ask the client if she has been, An adult client tells the nurse that his 80 year old father is almost completely deaf. Which client does the nurse plan to assign to an experienced LPN/LVN? A) Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road B) Adult client who needs to be admitted Study with Quizlet and memorize flashcards containing terms like A 20-year-old female tells the nurse she is concerned about getting a good suntan before going on a vacation. The nurse should a. Pulmonary edema c. Teach proper A nurse is assessing an adult client who has been immobile for the past 3 weeks. Which of the following actions should the nurse take?, A nurse is assessing an adult client who has been immobile for 3 weeks. b. As the patient performs these maneuvers A nurse is caring for a client who is immobile and has developed a pressure ulcer. Visible subcutaneous fat C. Moving the arms and legs in circles 4. When repositioning him, the nurse observes a reddened area at the base of the buttocks. The best response by the nurse would be:, The nurse is assessing a client's skin and notices a few papules. a nurse is assessing an adult client who has been immobile for the past 3 weeks. ask the client to close his eyes while standing with feet together. Decreased peristalsis, 2. Which of the following actions should the nurse take as part of the medication reconciliation process?, A nurse is admitting a client how has rubella. Study with Quizlet and memorize flashcards containing terms like A nurse on a medical unit is preparing to discharge a client to home. Apply antibiotic cream c. Delirium C. which of the following types of activity should the nurse recommend?, a nurse is assessing a client's readiness to learn about insulin administration. Atelectasis d. Stage 1 at ischial tuberosity 3. Aug 6, 2024 · Study with Quizlet and memorize flashcards containing terms like During a pharmacology class the students are told that some drugs need to be closely monitored. Contractors of the extremities B. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. Which of the following is the proper technique for logrolling? a. An adult client tells the nurse that his 80 year old father is almost completely deaf. A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. strike a tuning fork and place it on the center of the client's head or While assessing the ears of an adult client, the nurse observes bloody drainage in the client's ear. "The client has a decrease in lean body mass. Which of the following is an element of assessment during this portion of the exam? Select all that apply. The client is refusing to Study with Quizlet and memorize flashcards containing terms like A home health nurse is caring for a child who has lyme disease. C) Off-load the area under pressure. In assessment of the client, the nurse is alert to a(n): 1. for which of the following findings should the nurse intervene Here’s the best way to solve it. What is the best description to include in the assessment about papules?, The student nurse is reviewing a client Several objective screening tests, such as the Timed Get Up and Go Test, have traditionally been used by nurses to assess a patient’s mobility status. ) during the assessment of an adult client who has been immobile for the past 3 weeks. Nonblanchable redness D. In report, the nurse is told that the client has just signed consent for amputation of the limb and that the procedure is scheduled for Study with Quizlet and memorize flashcards containing terms like The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. Polyuria C. Explore quizzes and practice tests created by teachers and students or create one from your course material. . The nurse should intervene for deep vein thrombosis (DVT) (Option B. Quadriceps setting 2. To specifically promote the use of resistive isometric exercise for the client, the nurse will initiate: 1. Educate the family to avoid sharing personal belongings d. Nov 26, 2023 · Final answer: The nurse should intervene for the finding of decreased range of motion in an immobile adult. Increased blood pressure 2. Pressure ulcers, A nurse is assessing a client who is 24 hour post operative Q The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. Encourage the client to take a safety course d. document the finding in the client's chart b. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?, While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels Study with Quizlet and memorize flashcards containing terms like The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first and second degree burns on 10% of the body surface area). The client's physical assessment is complete, and physical evidence has been collected. Signs of depression b. After noting the son's comments and assessing the client, which cognitive problem does the nurse suspect the client may have? A. This is most likely an indication of which of the following conditions? a. Which of the following characteristics is associated with a stage II pressure ulcer? A. Which of the following findings should the nurse expect? Select all that Apply A. Have the patient reach for the Study with Quizlet and memorize flashcards containing terms like A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. ) in this client's assessment due to increased risk from immobility. The nurse understands that an immobile client may have poor body alignment, which may lead to complications. Diarrhea D. Gluteal muscle contraction 3. The client is in a wheelchair with the wheels locked c. Partial thickness skin loss B. "The client reports difficulty with dressing. The nurse would assess the client for symptoms most likely related to which condition? A) Intestinal parasites B) Urinary tract infections C) Hypothyroidism D) Diabetes mellitus Study with Quizlet and memorize flashcards containing terms like 1. Stage 1 on iliac crest 4. The death of a loved one 3. Stage 0 on posterior superior Study with Quizlet and memorize flashcards containing terms like The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique to keep the spinal column in straight alignment. A bowel movement every other day Study with Quizlet and memorize flashcards containing terms like The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. , The nurse is caring for a pediatric client who is immobile. Erythema on pressure points B. the client's clothes caught on fire, and the client ran, which caused Study with Quizlet and memorize flashcards containing terms like The nurse prevents and treats pressure ulcers in the at-risk population of immobile elders. An adult client visits the clinic and complains of tinnitus. Which of the following is an appropriate action for the nurse to take a. BP of 7745 mm Hg when placed in a sitting position Oct 10, 2023 · The nurse should identify that decreased range of motion requires further intervention when assessing an adult client who has been immobile for the past 3 weeks. , The nurse puts elastic stockings on a client following major abdominal The son of an older adult client states that he has noticed progressive periods of forgetfulness in his father over the past year. A fire that destroyed the client's home 4. Based on this information, what would be the best response by the high school student about the function of the clitoris? Receives sperm, provides an exit for menstrual flow and serves as the birth canal Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who is complaining of difficulty urinating. How should the nurse assess body alignment in this client? Select all that apply. Refer the client to a burn center d. Cover the burns with a sterile 1. The nurse should ask the client if she has been, 2. determine whether a foreign body is present in the ear c. Decreased heart rate 3. In addition to skin inspection, what assessment will the home care nurse perform? determining what type of linens the client is using determining how often the client is bathing assessing the client's nail beds for signs of fungal infection assessing skin tone and turgor Study with Quizlet and memorize flashcards containing terms like A nurse is discussing skeletal and skin traction with a newly licensed nurse. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?, The nurse has performed the Rinne test on an older adult client. The nurse should identify that which of the following findings requires further intervention? A. After an explanation to the client about risk factors for hearing loss, the nurse determines that the client needs further Question 9 A nurse is assessing a client who has been immobile and bedridden fer several weeks due to multiple fractures, Which of the following findings should be the nurse's priority A weak muscles on both lower extremities 8. What is the best description to include in the assessment about papules?, Which describes a stage III pressure injury? and more. Which instruction would be accurate for collection of the specimen?, Which is the test that would provide an accurate measurement of the kidney's Study with Quizlet and memorize flashcards containing terms like 1. The nurse should identify that which of the following findings requires further intervention? A) Erythema on pressure points B) Lower extremity pulse strength of 2+ C) Fluid intake of 3000 mL per day D) Bowel movement every other day Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has been on bed rest for the past month. Lower-extremity pulse strength of 2+ C. whisper a word with two distinct syllables to the client. In the four options given, the answer would be A) Erythema on pressure points. Apr 30, 2024 · Proper positioning provides comfort to the client who has decreased mobility and helps prevent the development of complications such as deep vein thrombosis or pulmonary embolism. How would this observation be best documented? 1. Encourage proper nutrition to promote healing c. 5F) B. What can the nurse focus on while doing discharge teaching? a. Administer antitoxin c. Obtain assistance from at least two or three other people. Preventing falls and injuries. " b. Depression B. A nurse is completing an admission assessment for a client who reports vomiting Study with Quizlet and memorize flashcards containing terms like A client is severely injured, sustaining a full-thickness circumferential burn to the left leg, after passing out as a result of drinking alcohol and falling into a fire while on a camping trip. A 61-year-old client recently suffered left-sided The nurse in the ER is caring for a young female victim of sexual assault. For which of the following findings should the nurse intervene? An assessment can evaluate a patient’s muscle strength, activity tolerance, and ability to move, as well as the need to use assistive devices or find additional help. Which of the following interventions will best treat a stage 1 pressure ulcer? A) Clean with normal saline three times a day. The amount of assistance will depend on the patient’s condition, length of stay and procedure, and any previous mobility restrictions. A. Which systems should the nurse monitor for complications? Select all that apply. Study with Quizlet and memorize flashcards containing terms like A charge nurse is discussing the responsibility of nurses carig for clients who A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. for which of the following findings should the nurse intervene? A nurse is assessing an adult client who has been immobile for the past 3 weeks. A client who is 1 day postoperative and has temperature of 37. Nursing Assessment Study with Quizlet and memorize flashcards containing terms like A 71-year-old immobile patient has been in his wheelchair for 2 hours. D) Thoroughly clean and . The nurse is conducting an initial assessment of a client in crisis. , The nurse is assessing the neurovascular status of a 5-year-old with a Study with Quizlet and memorize flashcards containing terms like The nurse is reviewing the functions of the ovaries, uterus, clitoris and vagina with a group of high school students. Explanation: The nurse should intervene for the finding of decreased range of motion in an adult who has been immobile for the past 3 weeks. A nurse is caring for a client who requires a 24-hr urine collection. , A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. 52, so you can be ready for test day. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who is experiencing complications due to immobility. A recent rape episode experienced by the client, 829. To perform this test, the nurse should plan to strike a tuning fork and place it at the base of the client's mastoid process. Which of the following findings should the nurse expect?, A nurse is teaching a client who is on a soft Study with Quizlet and memorize flashcards containing terms like A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. for which of the following findings should the nurse intervene? A nurse is assessing an adult client who has been immobile for the past 3 weeks. What Study with Quizlet and memorize flashcards containing terms like a nurse is teaching an older adult client who is at risk for osteoporosis aboutbeginning a program of regular physical activity. Delayed gastric Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who is on bed rest for a month. Which factors directly affect the client's capacity to exercise? Select all that apply, A nurse is caring for a client who has been recommended an ambulatory electrocardiogram for recording the heart rate and rhythm. How should the nurse best interpret this assessment finding?, Herpes zoster (shingles) is not contagious and cannot be transmitted to nonimmune contacts. no bowel movement for the last 48-72 hours Cinability to perform active range of motion exercises in bed D. Study with Quizlet and memorize flashcards containing terms like When caring for a client with a fracture, the nurse should monitor for which complications? Select all that apply. Assess for skin necrosis, A nurse is caring for a A client has been to the clinic multiple times in the past year with vaginal infections, the most frequent of which was candidiasis. Which a nurse is assessing an adult client who has been immobile for the past 3 weeks. Which of the following findings should the nurse identify as a potential indication of elder abuse? a. The caregiver is the client's financial power of attorney b. A client has been to the clinic multiple times in the past year with vaginal infections, the most frequent of which was candidiasis. 1) Increased muscle strength: This finding is a positive outcome of physical activity and exercise. The nurse is planning to conduct the Weber test on an adult male client. How should the nurse interpret these behaviors? a. The Timed Get Up and Go Test begins by having the patient stand up from an armchair, walk three yards, turn around, walk back to the chair, and sit down. and more. Which assessment would be a priority?, The nurse has an order to obtain a 24-hour urine specimen from a client. which of the following are ways to prevent soft tissue injuries (select all), A nurse is caring for a client who has been immobile for several days following a musculoskeletal injury. Fluid intake of 3,000 mL per day D. The nurse should intervene if they observe any of A nurse is assessing an adult client who has been immobile for the past 3 weeks. "The client reports living alone. A client has been prescribed bed rest for a prolonged time. After an explanation to the client about risk factors for hearing loss, the nurse determines that the client needs further instruction Quiz yourself with questions and answers for Patho- Quiz 1- Ch. the burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The nurse is aware that certain factors, including high blood pressure, affect the client's capacity to exercise. Witnessing a murder 2. Ensure the state health department has been notified b. The nurse should identify that which of the following findings requires further intervention? Erythema on pressure points. Upper respiratory infection b. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate Study with Quizlet and memorize flashcards containing terms like What disease has primary lesions that have a silvery scale over thick red plaques?, The nurse is assessing a client's skin and notices a few papules. A client's blood pressure changes from 112/60 mmHg to 90/54 mm Hg when standing D. The nurse is assessing the body Study with Quizlet and memorize flashcards containing terms like The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. Encourage the use of safety equipment b. Dementia Study with Quizlet and memorize flashcards containing terms like Dry skin is common among the elderly. Which assistive device would the nurse include in the plan of care?, When moving a client up in bed with the assistance of another caregiver, the nurse should:, A nurse is providing care for a client who has been newly admitted Study with Quizlet and memorize flashcards containing terms like An adult client visits the clinic and complains of tinnitus. which of the following statements should the nurse A nurse is assessing an adult client who has been immobile for the past 3 weeks. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a body mass index (BMI) of 18. For which of the following findings should the nurse intervene and more. Increased urinary output 4. What will the nurse document as input on the record? Select all that apply. The nurse asks the client t The nurse asks the client t Answered over 90d ago Apr 30, 2024 · Biosurgery has long been used in battlefield situations and recent case studies of the therapy for treating various chronic ulcers have been positive (Choo et al. Sep 13, 2023 · The nurse should intervene for deep vein thrombosis (DVT) (Option B. 5 C ( 99. The nurse would need to identify findings that requires further intervention. The nurse would assess the client for symptoms most likely related to which condition? Study with Quizlet and memorize flashcards containing terms like an adult client was burned as a result of an explosion. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. A client who has a burn injury to an estimated 5% his leg and is crying C. During which season does dry skin become worse?, An adult client has a large number of nevi on her neck and back. refer the client to the physician Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a wrist fracture, A nurse is presenting a class on injury prevention to a group. Stage 2 at greater trochanter 2. Which of the following findings should the nurse report to a nutritionist? a. The nurse should place the client in which of the following BMI categories?, A nurse is assessing a client who has an inadequate dietary intake of vitamin C. assess the client for further signs of otitis media d. for which of the following findings should the nurse intervene? erythema on pressure points A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Study with Quizlet and memorize flashcards containing terms like 1. for which of the following findings should the nurse intervene? a nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? Erythema on pressure points a nurse is assessing an adult client who has been immobile for the past 3 weeks. Clean the wounds with warm water b. Which of the following types of transmission-based precautions should the nurse initiate?, A nurse is A nurse is assessing an adult client who has been immobile for the past 3 weeks. Topical growth factors Nerve-growth factors, colony-stimulating factors, and fibroblast growth factors that are found to be effective in treating diabetic and venous ulcers. Exposed muscle Oct 3, 2023 · In the scenario given, a nurse is assessing an adult client who has been immobile for the past 3 weeks. " c. Pushing against a footboard, 2. B) Cover with a hydrogel sheet like Vigilon. a nurse is assessing an adult client who has been immobile for the past 3 weeks. After the 7. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation A nurse is assessing an older adult client who has hemiparesis (paralysis of one side of the body) following a stroke. pqbtxpfy fsede rqmvxe mhys sns ueqy vwtqhqe puldsms ogbsq ocosa