The nurse is performing a physical exam for a 9-year-old boy who complains of a stiff neck and pain in his arms and legs. He has never been vaccinated for polio. Which of the following assessment findings would suggest the child has polio?
A) Swelling in the neck
B) Confusion and anxiety
C) Positive Kernig's sign
D) Conjunctivitis
C
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The nurse is assessing a client's musculoskeletal system. Which action will the nurse perform first?
1. Assist the client to a standing position. 2. Assess the skin on the posterior legs. 3. Perform the Romberg. 4. Test range of motion and strength in the hips, knees, ankles, and feet.
A middle-aged patient with a history of type 1 diabetes is having a transmetatarsal amputation performed because a diabetic ulcer on his foot has failed to heal and threatens to develop into osteomyelitis
The OR nurse who is participating in the procedure recognizes the fact that the patient is at risk of hypothermia in the intraoperative period. How can the nurse best minimize this risk? A) Ensure that the surgical team maintains the room at a constant 28°C (82°F). B) Minimize the amount of IV fluids that are administered to the patient. C) Remove wet gowns and drapes from the patient as soon as possible. D) Encouraging physical activity before the administration of preanesthetics.
A 45 year-old adult male patient is admitted to emergency following a fall from a tree stand in which he sustained a large laceration to the occipital area of his head
The patient relates that prior to the fall, he had developed unrelieved chest pain that was present for approximately 20 minutes before he fell and is still present. The doctor diagnoses the patient with an MI and deep laceration to the head. To minimize cardiac damage, what physician's order will the nurse expect to see for this patient? A) Thrombolytics, oxygen administration, and bed rest B) Morphine sulphate, oxygen administration, and bed rest C) Oxygen administration, anticoagulants and bed rest D) Bed rest, albuterol nebulizer treatments, and oxygen administration
To protect against one of the adverse effects of using sodium hypochlorite for wound care the nurse should:
a. cleanse the wound with iodine prior to packing with sodium hypochlorite. b. monitor serum electrolyte level and hemoglobin and hematocrit levels. c. apply petroleum jelly to the skin around the wound. d. monitor for CNS symptoms