During assessment of the client with pneumonia, the nurse notes a bluish coloration of the skin. The nurse interprets this to mean the client is:
1. in the early stages of a respiratory problem.
2. improving.
3. hypoxic.
4. hyperventilating.
ANS: 3
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Which is not connected with the nursing home reform mandated by a 1987 law?
a. RAI b. HIPAA c. MDS d. UG
The nurse is admitting a client with suspected meningitis and notes a positive Brudzinski's sign has been noted in the history and physical. To validate this assessment finding, the nurse would note which of the following?
1. Seizure activity 2. Neck pain and stiffness 3. Flexion of the legs and thighs 4. Neck extension
Prophylaxis of subacute bacterial endocarditis is given before and after birth when a pregnant woman has:
a. Valvular disease. c. Arrhythmias. b. Congestive heart disease. d. Postmyocardial infarction.
During the history, a client reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this client?
a. There is 1+ edema of the feet and ankles bilaterally. b. The circumference of the right leg is larger than the left leg. c. There is patchy petechiae and purpura of the lower extremities. d. The feet are cool with capillary refill of toes greater than 3 seconds.