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A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

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

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 III?

When a patient is unable to see objects at a distance, which term is used to document this finding?

The nurse is working with a group of clients. Which clients are at risk for developing skin cancer? Which assessment findings are at risk for skin cancer (Select all 3 that apply)?

The nurse reviews the arterial blood gas results of a client and notes the following:  

pH 7.45, [normal range: 7.35-7.45]  

Paco2 of 30 mm Hg (30 mmol/L), [normal range: 35-45]  

HCO3- of 20 mEq/L (20 mmol/L), [normal range: 22-26]  

Which condition would the nurse analyze these results to indicate?

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

A nurse is caring for a client who recently had a stroke. Which alteration in neurologic function should the nurse expect?

A nurse is assessing a client for early manifestations of rheumatoid arthritis (RA). Which change is a manifestation of RA?

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?

A nurse in an emergency department is caring for a client who has abdominal pain.

Nurses' Notes 

0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk."

0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily.

0915: Fecal mass of hard, dry stool removed digitally from client per provider's order.

1015: Provided teaching to client and partner about constipation and methods to avoid further impaction.

Diagnostic Results

0900:

Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction.

A nurse is providing teaching to a client who has constipation. Which information should the nurse include? (Select all that apply.)