d. 3+ pitting edema of the lower extremities - answer✔a. Cyanosis of the fingertips
The nurse is assisting a client out of bed for the first time after surgery. What action should the
nurse do first?
a. Place a chair at a night angle to the bedside
b. encourage deep breathing prior to standing
c. help the client to sit and dangle legs on the side of the bed
d. allow the client to sit with the bed in a high Fowler's position - answer✔d. allow the client to
sit with the bed in a high Fowler's position
The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The
client attempts to use the left hand for feeding and other self-care activities. The spouse becomes
frustrated and insists on doing everything for the client. Based on this data, which nursing
diagnosis should the nurse document for this client?
a. situational low-self esteem related to functional impairment and change in role function
b. disabled family coping related to dissonant coping style of significant person
c. Interrupted family processes related to shift in health status of family member
d. risk for ineffective therapeutic regimen management related to complexity of care - answer✔b.
disabled family coping related to dissonant coping style of significant person
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