An 82 year old woman is being admitted to the long term care facility.  Her assigned nurse completes a full assessment, including calculating the risk for skin breakdown based on the Braden Scale.  Which of the following will the nurse not include to accurately calculate a Braden Scale value? 

An older client is observed having difficulty moving from a sitting to a standing position and has an unsteady gait. What should the nurse assess in this client to promote home safety? (Select all that apply.)

The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. His driver’s license states that he needs glasses to operate a motor vehicle, but no glasses were brought in with the patient. The nurse should

A client is at risk for developing a pressure ulcer and does not like to lie on his side. To enhance compliance, the nurse uses which of the following most effective explanation.

A nurse in a hospital is conducting a physical assessment with a partly undressed patient. What action by the nurse is most appropriate?

The student nurse performs orthostatic blood pressure readings during morning assessment. The results are: lying 146/78 mm Hg, sitting 128/68, and standing 110/62 mm Hg. What action by the nurse is best?

The nurse has identified several problems for a patient scheduled for a bone marrow transplant. By formulation of nursing diagnoses, the nurse:

The nurse writes an expected outcome statement in measurable terms. An example is: 

A patient requires frequent blood pressure (B/P) measurements after being admitted with a gunshot wound. The registered nurse (RN) is delegating the task of collecting B/P measurements to a licensed practical nurse (LPN). When delegating, the RN  knows which statement to be true?

The nurse responds to a patient’s call light. Upon entering the room, the nurse sees that the patient is lying on the floor, with bed linens around the legs. What is the most appropriate documentation for this incident?