The nurse reviewing the physician's diagnosis for a patient who has sustained a basal skull fracture knows that the patient should be observed for:
A) An area of bruising over the mastoid bone
B) Bleeding from the ears
C) An increase in pulse
D) Difficulty sleeping
Ans: B
Feedback: Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone; thus, they frequently produce hemorrhage from the nose, pharynx, or ears.
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The nurse administers a narcotic for pain to a terminal patient with end-stage pulmonary disease and dementia. After one hour, the patient exhibits facial grimacing and restlessness. How should the nurse interpret these assessment findings?
1. The patient has continuing pain. 2. The patient is experiencing a sleep disorder. 3. The patient requires comfort measures. 4. The patient assessment is is within normal limits.
Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant. Which is most likely, given this presentation?
A) Appendicitis B) Dysmenorrhea C) Ureteral stone D) Ovarian cyst
According to the care plan, the client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. When setting priorities, the home health nurse will:
1. Make sure that he or she is able to get to the client's home. 2. Assist the client in finding an alternative plan for the achieving the therapy's outcomes. 3. Tell the client that this therapy will be impossible to receive. 4. Make arrangements to have the client moved to a long-term care facility.
The mental health nurse at a community health center reviews the medical records of the patients who are scheduled for appointments. Which patient should the nurse see first?
1. A college student who has been referred from the student health center for an ADHD evaluation 2. A 43-year-old woman with schizophrenia who has stopped taking medication because of adverse effects 3. A 35-year-old woman with bipolar disorder who requires a medication evaluation 4. A 25-year-old man with obsessive-compulsive disorder who reports a relapse of symptoms