The emergency room nurse assessing clear drainage from the nose of a newly admitted patient with a head injury should perform which intervention?
a. Document the presence of rhinorrhea.
b. Inform the physician of the assessment.
c. Test fluid with a glucose Accu-Chek or Dextrostix.
d. Tape a drip pad under the nose.
C
The presence of glucose in the fluid from the nose confirms that the fluid is cerebrospinal fluid. Documentation and informing the physician should occur after confirmation of the character of the fluid.
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The nurse is planning to clean a client's wound. When cleaning a wound, the nurse should:
a. work in a circular motion. b. cleanse from the dirty area to the clean area. c. scrub the wound vigorously. d. cleanse from the clean area to the dirty area.
A client is admitted with acute osteomyelitis. A recent history of which of the following could be possible etiologies of this infection? (Select all that apply.)
A. Recent dental work B. Urinary tract infection C. Pregnancy D. Surgery E. Hemodialysis F. Gastrointestinal parasites
A hospitalized client diagnosed with depression asks a nurse, "Should I go home this weekend?" Which response by the nurse uses the technique of reflection?
A) "Should you go home for the weekend?" B) "Home means what to you?" C) "It sounds as if you don't want to go home this weekend." D) "I doubt that you really should go home this weekend."
In acute hypothermia, what physiologic change shunts blood away from the colder skin to the body core in an effort to decrease heat loss?
a. Hypotension b. Peripheral vasoconstriction c. Voluntary muscle movements d. Shivering