When giving catheter care, you need to hold the catheter at the:
a. Meatus
b. Vagina
c. Genitals
d. Perineum
A
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A victim of spousal abuse comes to the emergency department for treatment of a broken nose. She
appears hypervigilant and anxious and admits to sleep disturbance when the nurse questions the dark circles under her eyes. She reluctantly tells the nurse the abuse usually occurs when the husband has been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home mother of two preschool children. The family has lived in this town for 1 month. The client states she has fleetingly considered suicide but must stay alive to care for her children. She denies having had the desire to kill her husband. The assessments the nurse should document in the medical record include noting that (more than one option may be correct) A. signs of high anxiety and chronic stress are present. B. the client relies on the perpetrator for basic needs. C. the client is isolated from individual and community support. D. suicide risk is high. E. homicide potential is low. F. a safety plan should be constructed.
The nurse is performing a physical assessment on a client with undiagnosed back pain. The client is unable to communicate verbally
Which of the following vital sign values would indicate to the nurse that the client is in acute pain? Standard Text: Select all that apply. 1. Temperature of 100.6 degrees: 2. Pulse rate 94 3. Respiratory rate 32 4. Blood pressure 158/92 5. Facial grimacing
A client tells the nurse that she's not afraid to quit drinking because nothing bad will happen to her
Which condition, taught by the nurse, describes a serious and potentially fatal complication of alcohol withdrawal of which the client should be aware? A) Withdrawal delirium B) Neuroleptic malignant syndrome C) Tardive dyskinesia D) Cirrhosis
The nurse is planning care for an 8-year-old child with a concussion. Which is descriptive of a concussion?
a. Petechial hemorrhages cause amnesia. b. Visible bruising and tearing of cerebral tissue occur. c. It is a transient and reversible neuronal dysfunction. d. A slight lesion develops remotely from the site of trauma.