Question: 78 of 180
Time Remaining
Pause Humaining on
PALISE
A nurse is caring for a cere in the intencve care unt
The nurse is reviewing the admission assessment, nurses notes vital signs
and laboratory results. Drag words from the choices below to fill in each blank
in the following sentence.
Nurses Notes
Day 1, 1000
Left hip surgical wound warm, appears inflamed, and tender to
touch. Thick yellow discharge noted on dressing. Provider
notified.
Day 1, 1100
Nurse at bedside to assess the client. Client asks, "When am I
going home?" The client is oriented to person and place only.
Client states, "It's 1975." Client reoriented.
ay 1, 1200:
se found the client attempting to climb out of their hospital
Staff assisted client back in bed.
The nurse identifies that the client's f
Target 2
Findings
hallucinations
Musions
change in
orientation
past medical
history
-----
*
and
can indicate the development of delirium.