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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 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 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 assessing a client for manifestations of pain. Which finding is a subjective indicator of pain?

How should the nurse interpret the rhythm shown on the electrocardiogram strip shown in the diagram?

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?

A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following:

- pH is 7.12 (normal range: 7.35-7.45)

- PaCO2 is 90 mm Hg (normal range: 35-45)

- HCO3- is 22 mEq/L (normal range: 22-26)

The nurse interprets the results as indicating which condition?

 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 who has hyperthyroidism. The nurse should expect the client to report which manifestations?

To determine the quality and intensity of a cardiac murmur, the nurse would take which action?