A patient, with a gunshot wound to the knee, is complaining of groin and hip pain. The nurse realizes that this patient's pain might be because of which of the following?
1. cavitation
2. yaw
3. blast effect
4. tumble
3
Rationale: Tissue surrounding the missile tract is exposed to stretching, compressing, and shearing forces, which produce damage outside the direct path of the missile. Vessels, nerves, and other structures that are not directly damaged by the missile may be affected. The phenomenon of structure injury outside the direct missile path is referred to as "blast effect.". Cavitation is the formation of a cavity caused by the force of the missile. Yaw is the deviation of the missile either above or below the axis. Tumble is the action of forward rotation around the center of the missile or somersaulting.
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The nursing student is practicing blood pressure skills at a screening clinic. After taking a client's blood pressure several times, the student tells the instructor that the Korotkoff's sounds cannot be heard
Prior to the instructor's measuring blood pressure, the nurse should do which of the following to improve accuracy? 1. Have the instructor apologize to the client for repeated cuff inflation. 2. Have the client pump his fist to improve volume of Korotkoff's sounds. 3. Move the cuff to the other arm. 4. Have the client elevate his arm.
The nurse reminds a patient in active labor to perform cleansing breaths. Why should the nurse encourage the patient to do this type of breathing?
A) Ensures fetal perfusion B) Prevents hyperventilation C) Promotes hypoventilation D) Encourages cervical dilation
A nurse doing a daily weight on a child with diabetes insipidus notes the child has lost two pounds in 24 hours. The nurse should
1. continue to monitor the child. 2. notify the physician regarding theweight loss. 3. chart the weight and report the lossto the next shift. 4. do nothing more than chart theweight,as this would be a normal finding.
The ED nurse is caring for a client with a dissociative fugue. Which sign or symptom would the nurse expect to assess?
1. Pain in one or more sites 2. An inability to recall the past or where he had been 3. At least two distinct personality states 4. A deficit affecting voluntary motor or sensory functions