To assess cyanosis in a patient with a dark complexion, the nurse should inspect the: (Select all that apply.)
a. conjunctiva.
b. gums.
c. roof of the mouth.
d. nail beds.
e. palms of the hands.
B, C
A person with a dark complexion can be assessed for cyanosis by examining the gums and the roof of the mouth. Cyanosis is not usually apparent in the conjunctiva or palms of the hands. The nail beds tend to be darker in dark-skinned individuals so this would not render an accurate as-sessment of cyanosis.
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A single mother with three school-age children has recently noticed that the second child has been scratching his head and complains that it itches. She asks the school nurse to examine him. The school nurse notes that the child has head lice
Which of the following is the best description of head lice? a. Lice are easy to see and look like little white crabs. b. Lice are difficult to see, but their eggs are small oval particles. c. Lice and their eggs are on the hair shafts and look like dandruff. d. Treatment for lice can wait until the entire family can be checked.
___ identify process and outcome variables of interest
Fill in the blank with the appropriate word.
The nurse suspects acute graft rejection after a client has undergone a kidney transplant. What assessment findings confirm this diagnosis? (Select all that apply.)
a. Temperature of 100.6° F b. Blood urea nitrogen (BUN) 56 mg/dL c. Creatinine 3.2 mg/dL d. Urine output 20 mL/hr e. Extreme pain in the lower back f. Edematous ankles
The nurse is caring for an older client who presents with dizziness and difficulty hearing. Which of the nurse's assessment findings will require collaboration with the client's primary health care provider? (Select all that apply.)
a. Tympanic membrane is retracted, with multiple air bubbles. b. The client reports inability to hear high-frequency voices and sounds. c. Clear watery drainage is present in the ear canal and is positive for glucose. d. Tympanic membrane is shiny and trans-lucent, with light reflex noted. e. Hearing test indicates positive Rinne test, with AC > BC noted bilaterally. f. The client reports dizziness after taking naproxen (Aleve) for arthritis pain.