The nurse is performing an assessment on the client with breast cancer who has just returned from brachytherapy. The nurse is expecting which of the following findings on assessment?
1. Skin damp with sweat
2. Intact skin
3. Dry skin
4. Stretched skin
2. Intact skin
Rationale:
The goal for the client receiving radiation therapy to the chest is intact skin, which the nurse would expect to find. Skin that is damp with sweat, dry, or stretched is not consistent with radiation. If the goal were not met, the nurse would find excoriation.
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A parent tells the nurse, "I'm not sure how to give this medicine to my infant." How would the nurse teach the parent to best administer an oral suspension?
a. Pour the medication into a small cup and allowing the infant to drink it. b. Place the medication in a nipple and having the infant suck the nipple. c. Use an oral syringe and placing the medication in the side of the infant's mouth. d. Administer the medication with a dropper onto the back of the infant's tongue.
After leaving work, a nurse realizes documentation of administration of a PRN medication was omitted. This off-duty nurse phones the unit and tells the nurse, "Please document administration of the medication for me; I forgot to do it
My password is alpha1." The nurse receiving the call should: a. fulfill the request. b. refer the matter to the charge nurse to resolve. c. access the record and document the information. d. report the request to the patient's health care provider.
A nurse is seeing a patient with diabetes who reports that she thinks her diabetes is worse. She is feeling tired all the time, has difficulty enjoying things, and has problems concentrating and sleeping. What should the nurse consider in her assessment?
1. The patient may have social phobia. 2. The patient may have panic disorder. 3. The patient may have bipolar disorder. 4. The patient may have depression.
When conducting a physical examination on your patient, you determine that which of the following is a normal finding of lymph node examination?
a. nontender, fixed, hard nodes b. nonmobile, rubbery, erythematous nodes c. small, discrete, movable nodes d. enlarged node in the left supraclavicular area