Author Question: The nurse is admitting an elderly client at the change of shift. The client seems to be nodding yes ... (Read 39 times)

melina_rosy · **on:** Jul 22, 2018

The nurse is admitting an elderly client at the change of shift. The client seems to be nodding yes to every question. Which of the following nursing interventions is appropriate?

1. The nurse pulls the door shut to minimize the background noise.
2. The nurse raises her voice.
3. The nurse asks the client if he needs a hearing aid.
4. The nurse tells the client that they will talk later.

Question 2

The nurse assesses the client's fundus six hours after birth and shortly after the client voided 400 mL, and finds the fundus to be midline at the umbilicus and boggy. The nurse interprets this as an indication of:

1. A normal involution.
2. Retained urine.
3. Uterine bleeding.
4. Uterine trauma.

lindahyatt42 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1
Rationale: Pulling the door shut will give privacy and a non-distracting environment.

Answer to Question 2

3
Rationale: A large, boggy uterus is indicative of uterine bleeding, which can be caused by retained pieces of placenta and must be acted on quickly.