The client has a peritonsillar abscess. What is the priority instruction the nurse should provide to this client?
A. "If you notice an enlarged lymph node on the same side of your neck as the ab-scess, call the doctor."
B. "Stay home from work or school until your temperature has been normal for 24 hours."
C. "You may gargle with warm water that has a teaspoon of salt in it as often as you like."
D. "Take the antibiotic for the entire time it is prescribed, not just until you feel bet-ter."
D
Untreated or ineffectively treated peritonsillar abscesses can extend throughout the pharyngeal area, causing swelling that may jeopardize the client's airway.
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A highly suspicious client who has delusions of persecution about being poisoned has refused all
hospital meals for 3 days. Assuming all interventions listed are possible, the one likely to be most acceptable to the client is a. allowing the client to contact a local restaurant to deliver his meals. b. offering to taste each portion on the tray for the client. c. allowing the client supervised access to lobby food machines. d. providing tube feedings or total parenteral nutrition.
Mrs. L has refused permission for you to assess her breasts and genitalia. Being sensitive to legal considerations, your first response is to
a. ask a family member to convince her of the importance of this assessment. b. document her refusal and conclude the assessment. c. explain the importance of the assessment and repeat your request. d. notify the nursing supervisor to speak with the patient.
The male client who uses Humulin® insulin tells the nurse how he rotates the insulin injection sites. Which does the nurse include in client teaching about Humulin® insulin?
1. Rotating sites is not necessary with Humulin®. 2. Rotating sites is vital to prevent tissue damage. 3. Humulin® injections are given in the abdomen. 4. Humulin® absorption improves with site rotation.
Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant?
a. Assessing the infant for signs of trauma b. Administering prophylactic antibiotic agents to the infant c. Applying a cold pack to the infant's scalp d. Measuring the circumference of the infant's head