Patient information continued… The next morning, Mr. Jones reports feeling short of breath while getting out of bed to his chair. His vital signs are shown below. After five minutes sitting in the chair, he reported improvement in symptoms. On exam the nurse notes bilateral 2+ pitting edema in the lower extremities, crackles at lung bases bilaterally, jugular vein distention, and a third heart sound which was not noted by the previous shift. The patient is alert and oriented to person, place, and time with no evidence of dysrhythmia on telemetry monitors. The nurse evaluates the surgical incision, which appears unremarkable.    Temp 97.8 F oral   HR 108 bpm (reg)   BP 146/92   RR 28   O2 92%   Pain 3/10   Based on the above information what signs and symptoms are concerning?  

Patient information continued…  Mr. Jones was stabilized with diuretics and symptoms of dyspnea and edema resolved. He is preparing to be discharged home with his wife and daily visiting nursing services. He is feeling anxious about leaving the hospital; he feel uncertain about how strong his heart is and fears he may have another heart attack.    Mr. Jones is struggling with depression and anxiety following his myocardial infarction. Which of the following statements is true regarding mental health assessment?

Based on Mr. Jones’s clinical presentation, the nurse is most concerned for:

Patient information continued… Mr. Jones arrives at the emergency department of his local hospital. He already has IV access established from the paramedics. The nurse provides a does of oral nitroglycerin, starts Mr. Jones on supplemental oxygen via nasal cannula, and administers a dose of IV morphine. The physician has been notified of Mr. Jones’s arrival and is on his way from the floor. The nurse proceeds to perform her intake assessment of Mr. Jones.    When palpating the point of apical impulse, the nurse appropriately places her fingers on:

The nurse notes auscultation of a bruit in the right femoral region. What is a bruit?

When approaching the subjective assessment of chest pain, the nurse utilizes which mnemonic to gather pertinent information?

Patient information continued…Mr. Hanks has been managing his care at home with the assistance of his son. One morning, Mr. Hanks slipped and fell on an icy sidewalk while attempting to retrieve the morning paper. An open reduction and internal fixation (ORIF) was performed and the patient was admitted to a short-term rehabilitation to regain strength before returning home. After four weeks, it has been determined that Mr. Hanks may return home with visiting nursing services and home physical therapy visits. He will follow up with his primary care provider and orthopedist on a regular basis.    A critical function of the nurse is medication reconciliation. The process of medication reconciliation is best described as: 

When evaluating the geriatric patient, the nurse is incorrect in stating: 

The nurses current priority is to determine whether the chief complaint is related to uterine issues.  What are the focused questions that the nurse needs to ask the patient:

Patient information continued…Mr. Hanks has been on a cognition-enhancing medication and been takin part in local community center fall prevention exercise classes and denies any new falls. Mr. Hanks’s son reports following a home safety plan that the geriatric provider advised.   Which statements made by the son alert the nurse that he understood the teaching. (Select all that apply)