An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these?
a. Any change in the ability to hear
b. Any recent drainage from the ear
c. Recent history of trauma to the ear
d. Any prolonged exposure to extreme cold
ANS: D
Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.
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An appropriate use of guided imagery by a nurse would be to:
a. help cure cancer. b. help clients confront pain. c. decrease fever from infection. d. increase heart rate and blood pressure.
A patient is receiving radiation treatment for laryngeal cancer. Which ECG change would the nurse evaluate as indicating need to assess this patient for hypothyroidism?
1. Inverted T wave 2. Shortened PR interval 3. P wave inversion 4. Atrial fibrillation