A client is in a sitting position as the nurse palpates the temporal arteries and feels smooth, bilateral pulsations. Based on these data the nurse should:
a. Auscultate the temporal arteries for bruits.
b. Palpate the arteries with the client in supine position.
c. Document this as an expected finding.
d. Measure the client's blood pressure
ANS: C
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The nursing student is giving a bath to a client on the first clinical day. The physician arrives and removes a wound dressing, and tells the student to redress the wound. Which of the following actions should the student take?
1. Tell the doctor that wound dressings have not been covered in class yet. 2. Cover the wound with gauze. 3. Perform the dressing change. 4. Seek assistance from the instructor or nurse assigned to the client.
During a walk, an older male adult suffers a laceration from a broken tree branch. Rank the nurse's interventions in order, beginning with the most important intervention
a. Flush and cleanse the wound well. b. Investigate a possible safety hazard. c. Instruct him to keep wound covered. d. Verify a current tetanus immunization.
The patient tells the nurse she was reading about interferons on the Internet but still does not exactly understand what they do. What actions would the nurse describe as being performed by interferons? (Select all that apply.)
A) Prevent viral replication B) Suppress malignant cell replication C) Suppress tumor growth D) Stimulate T and B cells to initiate an immune response E) Stimulate the body to produce more T cells
A Native American hospitalized with auditory and visual hallucinations says, "My father said I should kill myself to save me from bad spirits." The patient's father is deceased. Which intervention would most appropriate?
a. After the patient becomes comfortable in the hospital setting, encourage description of the visions in a group setting. b. Explain to the patient that there are no evil spirits and these symptoms demonstrate grief related to the father's death. c. Obtain the patient's consent then consult the family for a spiritual healer from the patient's tribe. d. Provide the patient with private time to meditate and pray.