Which of the following patients would be most at risk for alterations in oral health?
A) infant who is breast fed C) woman who is pregnant
B) man with a nasogastric tube D) healthy young adult
B
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During the taking of a health history, the patient states, "It really hurts back there, and sometimes it itches, too. I have even seen blood on the tissue when I have a bowel movement. Is there something there?"
The nurse should expect to see which of these upon examination of the anus? a. Rectal prolapse b. Internal hemorrhoid c. External hemorrhoid that has resolved d. External hemorrhoid that is thrombosed
The nurse encounters a woman giving birth at the local mall. What should the nurse do first?
1. Apply counterpressure to the perineum. 2. Ask a bystander for a dry piece of clothing. 3. Visualize the perineum. 4. Determine if the membranes have ruptured.
A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, "Back off, bitch!" and then goes into the day room
Which intervention would be most important to undertake before the nurse follows the patient into the day room? a. Contact the patient's physician to obtain an order for seclusion. b. Review the patient's history for clues about his risk of violence. c. Assure that adequate staff are available and nearby for backup. d. Check for orders for PRN medication and prepare a sedative.
The nurse is concerned that a patient with injuries from a motor vehicle crash is experiencing bleeding from liver trauma. What did the nurse assess to make this clinical determination?
Select all that apply. 1. new onset of pruritus 2. new onset of lightheadedness 3. heart rate 112 beats per minute 4. requesting more water to drink 5. respiratory rate 26 breaths per minute