The priority action for the nurse when creating a plan of care for a client with newly diagnosed diabetes mellitus is to assess the patient's current condition and identify the level of self-management support required.
The nurse should also ensure the patient is educated about the basics of diabetes and how to manage it, provide dietary education, and prescribe appropriate medications. Evaluate the patient's health and lifestyle history.
Diabetes mellitus is a chronic disease that is characterized by high blood sugar levels (hyperglycemia) due to insulin resistance or deficiency. The nurse should assess the client's knowledge and understanding of diabetes to develop a tailored plan of care that meets the client's individual needs and goals.
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can you name the chronic disease of connective tissue characterized by edema, inflammation, and degeneration of skeletal muscles?
The chronic disease of connective tissue characterized by edema, inflammation, and degeneration of skeletal muscles is polymyositis. Thus, Option D is correct.
Polymyositis is a rare autoimmune disease that causes inflammation and degeneration of skeletal muscles, leading to weakness, fatigue, and difficulty with movement. It typically affects the muscles of the neck, shoulders, hips, and back, and may also cause difficulty with swallowing or breathing in severe cases. While the exact cause of polymyositis is unknown, it is thought to be related to an abnormal immune response that attacks muscle tissue.
Treatment usually involves corticosteroids and immunosuppressant medications to control inflammation and preserve muscle function.
This question should be provided with answer choices:
a. systemic lupus erythematosusb. myasthenia gravisc. rheumatoid arthritisd. polymyositisLearn more about polymyositis https://brainly.com/question/29220332
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the nurse is caring for a client receiving digoxin. the nurse monitors the client for which early manifestation of digoxin toxicity?
The early manifestations of digoxin toxicity include anorexia.
Digoxin toxicity is a condition that occurs when there is an excess of digoxin, a drug used to treat heart conditions, in the bloodstream. Symptoms of digoxin toxicity include confusion, abnormal vision, nausea and vomiting, irregular or slow heartbeat, fatigue, and difficulty breathing. Treatment for digoxin toxicity usually involves stopping the drug and providing supportive care. Other treatments may include dialysis, giving an antidote, or administering a beta-blocker to slow the heart rate.
It is important to note that certain medications, underlying health conditions, and dietary supplements can interact with digoxin, increasing the risk of toxicity. People who are taking digoxin should monitor their medication use and consult a doctor if they experience any of the symptoms of toxicity.
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which quality is the most important tool the nurse brings to the therapeutic nurse client relationship
Answer:
Empathy is considered the most important quality that a nurse brings to the therapeutic nurse-client relationship. It allows the nurse to understand and feel what the client is going through and helps build a trusting and supportive relationship. By being empathetic, the nurse can communicate effectively with the client, listen to their concerns and needs, and provide care that is tailored to their individual needs. Empathy also helps the nurse to provide emotional support and comfort to clients, which can be an essential aspect of their care.
Empathy is arguably the most important tool a nurse can bring to the therapeutic nurse-client relationship.
Empathy involves being able to understand and share the feelings of another person, without necessarily experiencing those feelings oneself. When a nurse is empathetic, they are better able to build trust with their clients, understand their needs and concerns, and provide care that is tailored to their individual situation.
Empathy also helps the nurse to communicate more effectively with their clients, as they are better able to convey their understanding and offer emotional support. Overall, empathy is a key component of building a positive and effective therapeutic nurse-client relationship.
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which assess ment technique is the most accurate when assessing resumption of peristalsis in a patient who underwent abdominal surgery 1 day ago?
The auscultation technique is the most accurate method of assessing the resumption of peristalsis in a patient who had abdominal surgery a day ago.
The method entails listening to the patient's abdomen with a stethoscope. When peristalsis resumes, a gurgling sound is produced, indicating the resumption of normal gastrointestinal activity. This method is non-invasive and requires little skill.
Resumption refers to the continuation of something after an interruption. In this case, it refers to the resumption of peristalsis in a patient after the surgical procedure.
Peristalsis is a wave-like contraction that pushes food through the digestive tract. It is a mechanism that propels food along the digestive tract, from the stomach to the anus.
Abdominal surgery is a surgical operation performed on the abdominal region of the body. It can be used to treat a variety of medical conditions such as cancer, infections, and injuries.
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which statements by the student nurse indicate effective learning regarding consensus building in the resolution of bioethical dilemmas? select all that apply.
The nursing student's statements a, b, c from the specify statements demonstrate the effective learning in building consensus on bioethical dilemmas.
Student nurse is a person who is training to be a nurse at a nursing school or hospital. Here student nurse's effective learning regarding consensus building indicates her to understand the educator point carefully and respond on it.
Consensus building is considered to be an act of discovery, as the best possible decision is reached on the basis of collective wisdom, which refer to harmonizing different points of view. When solving ethical dilemmas, consensus building focuses on promoting respect and agreement toward multiple philosophies instead of fixating on a particular moral system. It aims to build agreement among all participants in the decision-making process by encouraging respect for unusual viewpoints. Consensus building does not focus on a particular philosophy or moral system. Utilitarianism is based on seeking the greatest good for the greatest number of people.
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Complete question:
A registered nurse is educating the nursing student regarding the importance of consensus building in the resolution of bioethical dilemmas. Which statements by the student nurse indicate effective learning? Select all that apply.
a)Consensus building is an act of discovery.
b)Consensus building promotes respect and agreement.
c)Consensus building inspires respect for unusual points of view.
d) Consensus building is based on choosing a particular philosophy.
e) Consensus building is based on the greatest good for the greatest number of people.
which intervention does the nurse include in the plan of care for a patient with chronic obstructive pulmonary disease (copd) who is experiencing anxiety during acute dyspneic episodes?
The nurse should include cognitive-behavioral interventions in the plan of care for a patient with COPD who is experiencing anxiety during acute dyspneic episodes.
Cognitive-behavioral interventions are designed to identify and address cognitive distortions, irrational thoughts, and negative self-talk that may be causing or exacerbating the patient's anxiety. Interventions may involve teaching relaxation techniques, deep breathing exercises, distraction methods, and positive reframing.
The nurse should also work to identify and reduce any environmental factors that may be contributing to the patient's anxiety, such as noise levels, environmental temperature, and light levels. By providing the patient with the necessary support and interventions, the nurse can help reduce the frequency and intensity of their anxiety during acute dyspneic episodes.
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you are preparing a room to admit a person to a nursing center. the person is ambulatory. which is correct?
Prepare the room with safety features such as grab bars, slip-resistant floors, and clear pathways for mobility.
Since the person is ambulatory, they are able to move around on their own. However, they may still need assistance to prevent falls and ensure their safety. Therefore, it is important to prepare the room with safety features such as grab bars in the bathroom and near the bed, slip-resistant floors, and clear pathways for mobility.
This will help to prevent accidents and promote the person's independence. Additionally, it is important to ensure that the room is clean and comfortable, with appropriate lighting and temperature control, to ensure the person's comfort and well-being.
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a victim of a stab wound to the chest develops a pneumothorax. which type of pneumothorax is most likely in his case?
the newborn was diagnosed with esophageal atresia and a nasogastric tube was inserted. which findings are most consistent with this condition? select all that apply.
The most consistent findings with this condition are:
difficulty swallowing; inability to pass food from the mouth to the stomach;vomiting of fluid, bile, and/or undigested food;a nasogastric tube inserted for nutritional support.Esophageal atresia is a congenital disorder caused by abnormal development of the esophagus during fetal development. It affects the esophageal wall and causes a blockage, preventing food and liquid from passing into the stomach. Symptoms of this disorder include difficulty swallowing, inability to pass food from the mouth to the stomach, and vomiting of fluid, bile, and/or undigested food. A nasogastric tube may be inserted to provide nutritional support and to reduce the risk of aspiration.
In conclusion, the most consistent findings with a diagnosis of esophageal atresia are difficulty swallowing, inability to pass food from the mouth to the stomach, vomiting of fluid, bile, and/or undigested food, and a nasogastric tube inserted for nutritional support.
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a mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. the nurse monitors the client for which potential complication
The nurse should monitor the client for signs of respiratory depression, as atracurium and morphine are both drugs that can cause this.
What are the symptoms of respiratory depression?Respiratory depression is characterized by shallow and slow breathing, an increase in carbon dioxide levels, and decreased oxygen levels in the blood. Other signs include changes in heart rate and blood pressure, drowsiness, and confusion. The nurse should also monitor the client for hypotension, which is a decrease in blood pressure, as well as bradycardia, which is an abnormally slow heart rate. Additionally, the nurse should assess the client for signs of excessive muscle relaxation, as atracurium is a neuromuscular blocking agent.
This can lead to muscle weakness, loss of muscle tone, and difficulty swallowing or speaking. The nurse should also check for signs of allergic reactions, such as hives, swelling of the face, or difficulty breathing. Lastly, the nurse should monitor the client for signs of opioid toxicity, such as nausea, vomiting, confusion, drowsiness, and slowed breathing. It is important to note that opioid medications can cause addiction, so the nurse should take steps to ensure proper dosage and monitor the client's response.
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the nurse is creating a plan of care for a client. which actions by the nurse demonstrate the components of the nursing process? select all that apply.
The nursing when working in systematic, problem-solving approach with patient care consists of obtaining vital signs, documenting the nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level.
Hence, A is the correct option
In general , the actions by the nurse that include components of the nursing consists of following a thorough assessment for client's health Together with Analyzing all the given data from assessment by identifying the actual and potential health problems
Nurses' also need to Develop a plan that include direct goals and interventions to solve client's issues and achieve desired outcomes. Carrying out the plan of care by providing nursing interventions. Evaluating the effectiveness of the plan of care by monitoring the client's response to interventions and modifying the plan of care as needed.
Hence, A is the correct option
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-- The given question is incomplete , the complete question is
The nurse is creating a plan of care for a client. which actions by the nurse demonstrate the components of the nursing process?
A. Obtaining vital signs, documenting the nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level.
B. Taking a client's health history only.
C. Comparing client outcomes against planned goals
D. Not Prioritizing on activities that works in improving client comfort.
an older adult recovering from anesthesia for a surgical procedure develops delirium. which action(s) will the nurse take to help this client? select all that apply.
The nurse should take the following actions to help an older adult recovering from anesthesia for a surgical procedure who develops delirium:
Provide a safe, calm environmentEncourage family/caregiver involvementEncourage orientation to person, place, and timeReduce the use of physical restraintsProvide supportive care measures
Providing a safe, calm environment is important as delirium can cause confusion and disorientation. Encouraging family/caregiver involvement can help orient the patient and reduce agitation. Orientation to person, place, and time can also help, as can reducing the use of physical restraints and providing supportive care measures.
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the nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. which response from the mother indicates a need for further teaching?
The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. A response from the mother indicating a need for further teaching would be if she does not understand the differences between an umbilical hernia and an inguinal hernia.
An umbilical hernia is when the intestines push through the opening of the umbilical cord, while an inguinal hernia is when the intestines push through the lower abdomen near the groin. Therefore, if the mother does not understand the differences between the two, then it would be indicative of a need for further teaching.
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the caregiver of a child who has had a cast applied to the leg observes the nurse putting adhesive tape strips around the edge of the cast. the caregiver asks the nurse why she is doing this. the best response by the nurse would be:
The best response by the nurse would be, "The adhesive tape is used to protect the edges of the cast and prevent it from cracking or breaking, which can cause discomfort for the child."
The adhesive tape is used to protect the edges of the cast and prevent it from cracking or breaking, which can cause discomfort for the child. This will also make the cast more secure and durable.
The caregiver of a child who has had a cast applied to the leg observes the nurse putting adhesive tape strips around the edge of the cast. The caregiver asks the nurse why she is doing this.
The best response by the nurse would be as mentioned above. It is essential to give an accurate and factually correct answer to the caregiver to ensure the child's safety and well-being.
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a nurse is providing instructions for home cast care. which response by the parent indicates a need for further teaching?
Response indicating a need for further teaching for the parents is "Pale, cool, or blue skin coloration is to be expected."
Pale, cool, or blue skin coloration is not normal and could be a sign of poor circulation or other complications. The parent should be instructed to monitor the skin around the cast and report any changes in color or sensation to the healthcare provider immediately.
Any signs of circulation impairment, such as swelling, pain, or numbness, should also be reported promptly. It's important to provide clear and accurate instructions to parents and ensure they understand the potential complications associated with cast care.
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which laboratory information will the nurse assess to detect if hit develops ina client who is receiving a continuous heparin infusion
Answer:
Activated partial thromboplastin time (aPTT)
Explanation:
Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels.
a new unlicensed assistive personnel (uap) is preparing to ambulate an obese client. the registered nurse (rn) is concerned about the ufos ability to safely ambulate the client. which would be the nurse's most appropriate action?
The nurse's most appropriate action when an unlicensed assistive personnel (UAP) is preparing to ambulate an obese client and the RN is concerned about the UAP's ability to safely ambulate the client is to supervise and provide guidance while the UAP ambulates the client.
An unlicensed assistive personnel (UAP) is an individual who is not licensed as a medical practitioner but is trained to assist licensed medical practitioners in the care of patients. They are commonly known as nursing assistants, nursing aides, or orderlies, and their roles vary depending on the location and the medical facility. They are generally supervised by a registered nurse or a licensed practical nurse.
Ambulation is the process of walking, and when a UAP is preparing to ambulate an obese client, the RN is concerned about the UAP's ability to safely ambulate the client, they must supervise and provide guidance to ensure the patient's safety. In summary, when an unlicensed assistive personnel (UAP) is preparing to ambulate an obese client, and the registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client, the nurse's most appropriate action is to supervise and provide guidance while the UAP ambulates the client.
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the nurse is reviewing the biophysical profile (bpp) results and would expect which variables to be included in this test? select all that apply.
The score is less than 8, then there may be a need for further evaluation or intervention.
The nurse would expect the following variables to be included in the biophysical profile (BPP) test:
• Fetal breathing movements
• Fetal tone
• Fetal movements
• Amniotic fluid volume
• Nonstress test (NST)
The Biophysical Profile (BPP) is an ultrasound-based test that is used to evaluate the fetal well-being during pregnancy. The test assesses five variables that are indicative of fetal health. These five variables include fetal breathing movements, fetal tone, fetal movements, amniotic fluid volume, and nonstress test (NST). The test is generally performed in the third trimester of pregnancy and is usually done when there is a suspected risk to the fetal health.
Each variable is scored either 0 or 2 based on the presence or absence of a specific observation. A score of 2 is given when a normal result is obtained, and a score of 0 is given when an abnormal result is obtained. The BPP score ranges from 0 to 10. A score of 8 to 10 is considered normal and indicates the fetal well-being. However, if the score is less than 8, then there may be a need for further evaluation or intervention.
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which slightly elevated laboratory result would the clinician observe in a patient with idiopathic hirsutism
A clinician would observe an elevated serum testosterone level in a patient with idiopathic hirsutism. This can be confirmed through a laboratory test.
Idiopathic hirsutism is a condition characterized by excessive hair growth in women that is not caused by an underlying medical condition or medication. In some cases, idiopathic hirsutism may be associated with elevated levels of androgens, such as testosterone, which are male sex hormones that are also present in women in smaller amounts.
To confirm the presence of elevated serum testosterone levels in a patient with idiopathic hirsutism, a clinician may order laboratory tests such as a total testosterone test or a free testosterone test. These tests measure the amount of testosterone in the bloodstream and can help diagnose conditions such as polycystic ovary syndrome (PCOS) or adrenal hyperplasia that can cause elevated androgen levels and hirsutism.
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keeping in mind l.j.'s health history and admitting diagnosis, what are the 2 most important assessments you will make during your physical examination and assessment?
Keeping in mind L.J.'s health history and admitting diagnosis, the two most important assessments to be made during a physical examination and assessment are neurological assessment and cardiovascular assessment.
Neurological Assessment is an important assessment, given that L.J.'s admitting diagnosis is a head injury. This will enable one to determine the extent of the injury, identify any abnormal neurological responses, and provide appropriate care.
Cardiovascular Assessment is the second most important assessment, which will help to establish L.J.'s overall heart health and help to identify any underlying conditions that may have contributed to his current illness or injury.
In general, during the physical examination, it is important to assess the vital signs, skin color, temperature, and texture, as well as the musculoskeletal and respiratory systems. This will help to identify any underlying medical conditions that may need to be addressed to ensure that the patient is receiving appropriate care.
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a client who has been severely beaten is admitted to the emergency department. the nurse suspects a basilar skull fracture after assessing:
A client who has been severely beaten is admitted to the emergency department, the nurse suspects a basilar skull fracture after assessing the presence of a raccoon sign.
A basilar skull fracture occurs when the skull's bone at the base of the brain is broken, the fracture of the skull can cause blood to flow from the ears, nose, and mouth. Basilar skull fractures can also cause significant brain damage, meningitis, and other complications. The signs and symptoms of basilar skull fracture are the presence of a raccoon's sign can be determined by the nurse, ecchymosis is another name for a raccoon's eye, which is also known as periorbital ecchymosis. This is a bruising around the eyes, which can be a sign of a basilar skull fracture or brain injury.
Battle sign is another term for mastoid ecchymosis, which is a bruise behind the ear, this condition indicates that the basal skull has been injured. Due to cerebrospinal fluid leakage from the ear, a patient may experience hearing problems, otorrhea, or rhinorrhea. A basilar skull fracture can also cause some other symptoms including headache, nausea, vomiting, stiff neck or pain in neck, slurred speech, blurred vision, or other vision problems, confusion, loss of consciousness or coma. For any further information regarding the condition, please refer to a medical practitioner.
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when inspecting the nails of a patient with dark skin, what would the nurse expect to record as normal findings?
smokers who have chronic bronchitis have a greater risk of lung cancer. group of answer choices true false
Smokers who have chronic bronchitis have a greater risk of lung cancer is true, because chronic bronchitis is an inflammation of the bronchi in the lungs that can be caused by smoking
The inflammation of the bronchial tubes caused by chronic bronchitis weakens the body’s defenses, making it more susceptible to the carcinogenic effects of tobacco smoke. Smoking increases the risk of lung cancer by five to ten times for those with chronic bronchitis. It is also worth noting that the earlier a person begins smoking, the more likely they are to develop lung cancer. Therefore, it is very important for those with chronic bronchitis to avoid smoking and to seek medical help if they are already smoking.
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to address chronic malnutrition, it is especially important to provide . question 11 options: carbohydrates fats protein sugars water
The best way to address chronic malnutrition is to provide a balanced diet that includes a combination of carbohydrates, fats, proteins, and vitamins and minerals. Drinking plenty of water is also important for overall health. Therefore, the correct answer is A, B, C, and E.
Chronic malnutrition is a form of undernutrition that affects an individual's long-term health and growth. It is caused by an insufficient and/or imbalanced diet, inadequate healthcare and/or access to education and resources, or a combination of these factors. The long-term effects of chronic malnutrition can include stunted physical growth, impaired cognitive and physical development, and even mortality. Common symptoms include wasting, stunting, anemia, and micronutrient deficiencies.
Chronic malnutrition can lead to lifelong problems, and can severely limit one’s physical and intellectual potential. To prevent and reduce chronic malnutrition, we must focus on access to and education about healthy diets, healthcare and medical treatment, and access to resources.
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what is the dietary reference intake for dietary fiber? 35-50 grams/day 25-35 grams/day 15-25 grams/day 15-20 grams/day
The dietary reference intake for dietary fiber is 25-35 grams/day. The correct option is B.
Dietary fiber is the edible component of plant food that is resistant to digestion and absorption in the small intestine. It arrives unchanged in the colon, where it is fermented and provides energy for the growth of good bacteria in the large intestine.Dietary fiber is categorized into two groups: soluble and insoluble fiber. Soluble fiber dissolves in water and forms a gel-like substance in the digestive system, while insoluble fiber does not dissolve in water and passes through the digestive system unchanged.The dietary reference intake for dietary fiber is 25-35 grams/day. It is recommended that everyone consume a variety of nutrient-dense foods that are high in dietary fiber, such as fruits, vegetables, whole grains, legumes, nuts, and seeds, to promote good health and prevent chronic illnesses. Therefore, the correct answer is B.Learn more about Dietary reference: https://brainly.com/question/959682
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A charge nurse is evaluating a newly licensed nurse's understanding of advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of advance directives?
A. "I'll refer clients who do not have advance directives for legal assistance"
B. "I have to witness a client's signature on his advance directives"
C. "I have to document whether or not a client has prepared his advance directives"
"D. I'll encourage clients to follow their provider's wishes for end-of-life care"
A charge nurse is evaluating a newly licensed nurse's understanding of advance directivesThe following statement by the newly licensed nurse indicates an understanding of advance directives is d. "I'll encourage clients to follow their provider's wishes for end-of-life care".
Advance directives are guidelines that clarify the medical care that someone wishes to receive when they are unable to communicate their wishes. They're important since they allow people to maintain control over their health care even when they're unable to make their own choices, according to the American Hospital Association.
An advance directive is a legal document that everyone can sign. It is accessible to anyone who is 18 years old or older and legally competent. It is possible to draft an advance directive at any moment, and it is a good idea to do so when you are well, so that your loved ones know what you want if you are unable to make decisions.
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a client presents to the emergency room with a possible diagnosis of appendicitis. the health care provider asks the nurse to assess for tenderness at mcburney's point. the nurse knows to palpate which area?
The nurse knows to palpate the right lower quadrant of the abdomen to assess tenderness at McBurney's point in a client who presents to the emergency room with a possible diagnosis of appendicitis.
Explanation:Appendicitis is inflammation of the appendix, which is a small, thin, tube-like structure that extends from the large intestine's lower end. It's usually a surgical emergency that's caused by an obstruction in the appendix, and it's one of the most frequent abdominal illnesses requiring surgery.
What is McBurney's point?McBurney's point is a point on the right side of the abdomen that is located one-third of the distance between the anterior superior iliac spine and the umbilicus (belly button). McBurney's point is frequently used to describe the site of pain related to appendicitis in the right lower quadrant of the abdomen.
How to palpate at McBurney's point?To palpate the area for tenderness at McBurney's point in a client who presents to the emergency room with a possible diagnosis of appendicitis, the nurse should:
Ask the patient to lie flat on the back and expose the right lower quadrant of the abdomen, just below the umbilicus.Palpate the area using the fingertips of the right hand, applying pressure with each fingertip while pushing downward and inward towards the patient's spine with the other hand.Begin palpation at the navel and move towards the right side of the abdomen slowly while observing the patient's reaction.If tenderness or pain is found upon palpation, it is noted and reported to the healthcare provider.To know more about appendicitis, visit: https://brainly.com/question/29572150
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the nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?
A nurse should consider the following domain when developing a nursing diagnosis based on this client's musculoskeletal health problems:
Mobilization
Difficulty with ambulation
Impaired physical mobility
According to the given scenario, the patient has a fractured femur, and due to the fracture, he/she is in traction. Therefore, the patient must be restricted to bed rest for some time. As a result, the nurse must develop a plan of care that addresses the client's immobility issues.
Impaired physical mobility is a musculoskeletal-related nursing diagnosis that should be considered when developing a plan of care. This nursing diagnosis is defined as a limitation of independent and purposeful movement of the body or body segments. It is a universal human experience that has many different etiologies.
Additionally, difficulty with ambulation and mobilization are two additional domains that should be considered for a patient with a musculoskeletal injury.
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this patient had a bilateral knee replacement, unicompartmental on the medial side, placed with cement. how is this coded?
The procedure is coded as a bilateral knee replacement with unicompartmental component on the medial side and cement fixation using ICD-10-PCS code 0SRH0JZ.
The ICD-10-PCS (International Classification of Diseases, Tenth Revision, Procedure Coding System) code 0SRH0JZ represents a total knee replacement procedure with cemented fixation, and the addition of the character "1" in the fifth position specifies a unilateral procedure, while "2" specifies a bilateral procedure.
The use of the term "unicompartmental" refers to the fact that only one side of the knee joint was replaced, and "medial" specifies the location of the replacement. Therefore, the appropriate code for this procedure would be 0SRH02Z to indicate a bilateral knee replacement with unicompartmental component on the medial side and cement fixation.
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in which order of priority would the nurse complete the assessment of a client who is severely injured with burns and has sustained major trauma?
The nurse should assess the severity of the burns and the trauma sustained in the following order of priority: 1) Airway and breathing, 2) Circulation and bleeding, 3) Disabilities (neurological), and 4) Exposure/environmental control.
Airway and breathing: The nurse will assess the client's airway to make sure it is open and the client is breathing.
Circulation and bleeding: The nurse will assess the client's circulation, including their blood pressure, pulse, and capillary refill.
Neurological disability: The nurse will assess the client's level of consciousness and neurological function.
Exposure: The nurse will assess the client's body for any other injuries or burns that need treatment.
All other assessments should be based on the assessment of these four elements, including the assessment of the patient's vital signs.
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