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A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?

Mr. Sprat is a 21-year-old patient who complains of nasal congestion. He admits to using recreational drugs. On examination, you have noted a septal perforation. Which recreational drug is commonly associated with nasal septum perforation?

A patient with a history of duodenal ulcer is admitted to the emergency department with reports of pain. The nurse should assess for this pain by palpating in which abdominal quadrant?

A nurse is caring for a client who has a body mass index (BMI) of 26. The nurse should place the client in which BMI category?

A nurse is preparing a program on osteoporosis for a local women's group. Which of the findings does the nurse recognize as a modifiable risk factor?

A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

Providing a safe and comfortable environment, applying critical thinking, and identifying cues presented by the patient is

A nurse is caring for a postoperative client. The nurse should base the client's pain management interventions primarily on which methods of determining the intensity of the client's pain?

Which shape should the nurse expect a client's chest to be when assessing a client who has COPD?

 A nurse in an emergency department (ED) is admitting a client.

Vital Signs 

1000:

Temperature 38.6° C (101.5° F)

Heart rate 106/min

Respiratory rate 26/min

Blood pressure 110/54 mm Hg

Oxygen saturation 94% on room air

Nurses Notes 

1000:

Client presents to ED with report of shortness of breath for 3 days, with headache, chills, fever, sore throat, and cough.

Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.

Client's face is flushed, sinus tachycardia, rate of 106/min, $152 heart sounds heard on auscultation. Pulses palpable.

Breath sounds with crackles to right lower lobe, tachypnea, rate of 26/min. Tactile fremitus and decreased lung expansion noted upon assessment. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."

Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."

Reports decreased urination in the past day.

Client reports they have not had a pneumococcal vaccine. States, "1 Just hate needles."

Diagnostic Results

1030:

Chest x-ray.

Areas of increased density and white infiltrates to lower right lobe.

Select 3 objective findings in the client's medical record that may be indicative of pneumonia.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve II?