When percussing the scapula of a client, which of the following would the nurse expect to hear?
A) Resonance
B) Dullness
C) Flatness
D) Hyperresonance
C
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The nurse is caring for a woman in the emergency room who is complaining of chest pain. She states that she was walking from her apartment to the grocery store when the pain became very severe. She reported that people were following her
She said she couldn't really see them but she could hear them talking about "grabbing me." While the woman is explaining the event, she alternates between wringing her hands and manipulating the items in her purse over and over. The nurse would obtain what further assessment data in this situation? 1. Spiritual affiliations 2. Dietary preferences and habits 3. Review of systems 4. Focused psychosocial interview
A gravida patient at 32 weeks of gestation reports that she has severe lower back pain. The nurse's assessment should include
a. Observation of posture and body mechanics b. Palpation of the lumbar spine c. Exercise pattern and duration d. Ability to sleep for at least 6 hours uninterrupted
To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse would consider the following clinical information. (Select all that apply.)
a. These are both normal presentations because of the birth process and will resolve within 24 to 48 hours. b. Cephalohematoma manifests as a localized area of swelling as compared with caput succedaneum, which appears as a general swelling of the head. c. A cephalohematoma can develop several hours or days after the birth event, whereas caput succedaneum is noted shortly before or immediately after the birth event. d. Edema that crosses suture lines is observed with caput succedaneum. e. With a cephalohematoma, bleeding occurs between the bone and skull.
A patient with Parkinson disease is demonstrating bradykinesia. The nurse will likely observe which action in this patient?
1. slowed or delayed movements 2. increased spontaneous movements 3. active exercise and high energy 4. very slow talk