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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?

 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.

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

Ms. Hartzel is a 33-year-old patient who presents to the office with complaints of enlarged lymph nodes in her neck. During your examination, which part of the hand is used to assess lymph node size?

The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)

The nurse is assigned to care for a client with complete right-sided hemiparesis [weakness] from a stroke (brain attack).

admitting diagnosis

cerebrovascular attack

Right-sided hemiparesis

Which characteristics are associated with this condition? Select 2 that apply.

To assess the tympanic membrane mobility, which instrument is most appropriate for the nurse to use?

A nurse is receiving a patient from the emergency room (ER) with an admitting diagnosis of hypothyroid disorder. 

Admitting diagnosis

acute hypothyroid disorder

Physician order

Synthroid 0.1 mg po daily

The receiving medical- surgical nurse would expect the patient to exhibit which signs and symptoms? Select all that apply

Which finding should the nurse expect when assessing a client who is cyanotic?

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?

A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?