What assessment does the school nurse recognize as the cardinal sign of a hyphema?
a. Opacity of the lens
b. A yellow-white reflex on the pupil
c. A dark-red spot in front of the iris
d. Inflamed mucous membranes of the eyelids
ANS: C
A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.
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A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?
a. Prepare to administer vancomycin (Vancocin). b. Strictly limit visitors to immediate family only. c. Wash hands only after taking off gloves after care. d. Wear a respirator when handling urine output.
The student nurse asks how the nurse will know when the client has actually died. The nurse tells the student nurse about the signs of brain death and biological death. When does the client experience biological death?
A) Irreversible coma B) Pupils fixed and dilated C) Irreversible cessation of all functions of the brain D) Absence of respirations and the absence of a heartbeat
Which nursing advocate worked to encourage respect for cultural diversity and was America's first African American professional nurse?
a. Lavinia Dock c. Adelaide Nutting b. Mary Mahoney d. Linda Richards
An older patient is experiencing diarrhea and has recently been diagnosed with Clostridium difficile? This tends to occur in which type of patient?
1. A patient with a history of ulcerative colitis 2. A patient who has had a recent bout of pneumonia 3. A patient who has been on steroids for several months 4. A patient who has consistently had a nutrient poor diet