The nurse is caring for an infant born at 43 weeks. What would the physical assessment reveal?
a. Dry, peeling skin
b. Minimal hair on the head
c. Short, rough nails
d. Abundant lanugo on the body
ANS: A
Loss of vernix caseosa leaves the skin dry, causing peeling.
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A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should:
a. Document the presence of hepatomegaly. b. Ask additional health history questions regarding his alcohol intake. c. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. d. Consider this finding as normal, and proceed with the examination.
The nurse is caring for a patient on the GI floor who has anemia. When reviewing the patient's recent lab work, which lab test would the nurse expect to be decreased?
a. Total bilirubin b. Hemoglobin and hematocrit c. Serum amylase d. Ova and parasites
An older adult patient who has cancer and Alzheimer's disease is crying but shakes her head "no" when asked about pain
The prescriber has ordered morphine sulfate 2 to 4 mg IV every 2 hours PRN pain. It has been 4 hours since a dose has been given. What will the nurse do? a. Administer 4 mg of morphine and monitor this patient's verbal and nonverbal responses. b. Give 2 mg of morphine for pain to avoid increasing this patient's level of confusion. c. Request an order for a nonopioid analgesic or an antidepressant adjuvant analgesic. d. Withhold any analgesic at this time and reassess the patient in 30 to 60 minutes.
Which classic symptom is indicative of invasive gynecologic cancer in an older patient?
a. Swelling of one leg b. Dark and foul smelling discharge c. Painless vaginal bleeding d. Flank pain