A patient is visiting an urgent care center after being hit in the back with a baseball. Upon examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in color. How does the nurse document this lesion?
a. As an angioma
b. As purpura
c. As petechiae
d. As ecchymosis
ANS: D
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A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. What nursing diagnosis is the priority in this client's care?
A) Impaired gas exchange related to the disease condition B) Impaired verbal communication related to the breathing problem C) Inability to speak due to ineffective airway clearance D) Impaired physical mobility related to shortness of breath
Pernicious anemia occurs because of the lack of intrinsic factor that is necessary for the absorption of vitamin B12. Older clients are at risk for this anemia because of
A) a decrease in hydrochloric acid in the stomach. B) decreased peristalsis in the gastrointestinal tract. C) the tendency for older clients to be dependent on laxatives. D) an increased incidence of cholelithiasis.
A young woman is being treated with amoxicillin (Amoxil) for a urinary tract infection. Which is the highest priority instruction for the nurse to give this client?
a. "Use a second form of birth control while on the drug." b. "You will experience increased menstrual bleeding while on this drug." c. "You may experience an irregular heart-beat while on the drug." d. "Watch for blood in your urine while tak-ing this drug."
A client is exhibiting anxiety after being told that her husband has sustained a heart attack. The nurse's response to the client is "Everything will be okay."
Which of the following types of nontherapeutic communication techniques is being exhibited by the nurse? A) Failure to listen B) Judgmental attitude C) False reassurance D) Giving advice