Your 12-month-old client has had repeated ear infections. The parent has noticed that the client does not look toward the sources of noises and has not started to vocalize. Which nursing diagnosis would be most appropriate?
1. Social isolation
2. Impaired verbal communication
3. Disturbed sensory/perceptual: auditory
4. Self-care deficit
ANS: 3
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A child has had eye testing. The nurse reads in the child's chart that the Hirschberg test demonstrated displacement of light reflection in one eye. What does this indicate to the nurse?
A. Color blindness B. Normal ocular alignment C. Presence of cataracts D. Presence of strabismus
At which point in the physical examination should the nurse assess a patient's vital signs?
A) After the integumentary status examination B) After the cardiovascular system examination C) After the respiratory system examination D) After the body measurements examination
When assessing a client diagnosed with Parkinson's disease for evidence of inadequate drug management of the disease, the nurse anticipates the client will exhibit which of the following manifestations?
a. shuffling unsteady gait c. urinary retention b. nausea and vomiting d. orthostatic hypotension
You feel a small mass that you think is a lymph node. It is mobile in both the up-and-down and side-to-side directions. Which of the following is most likely?
A) Cancer B) Lymph node C) Deep scar D) Muscle