The nurse assesses the client with which condition first?
a. Folliculitis
b. Furuncles
c. Cellulitis
d. Stage II ulcer
C
The client with cellulitis has a generalized infection with Staphylococcus or Streptococcus that involves deep connective tissue. The client with folliculitis has a superficial infection of the upper portion of the follicle, and the client with furuncles has a deeper infection in the hair follicle. A client with a stage II ulcer with no infection is less of a priority.
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The nurse is assessing cranial nerve XI (spinal accessory). Which statements would the nurse say to the client in order to complete this assessment?
1. "Shrug your shoulders and turn your head against my hand." 2. "Stick out your tongue and move it from side to side." 3. "Taste these foods and decide which is sweet and which is sour." 4. "Smell these items and identify what they are."
A client who is breastfeeding her newborn states, "I noticed that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?
A) "Your uterus is still shrinking in size, that's why you're feeling this pain." B) "Let me check your vaginal discharge just in case to make sure everything is fine." C) "Your body is responding to the events of labor, just like after a strenuous workout." D) "The baby's sucking releases a hormone in your body causing the uterus to contract."
A patient's initial assessment revealed blood pressure 128/70, pulse 68, respirations 20, and pupils equal and reactive. The patient is awake and responding to verbal stimuli but demonstrating weakness on the left side
A medical diagnosis is presumptive stroke. Two hours later the patient is not awake but is easily aroused, has a blood pressure of 140/70, pulse 52, respirations 18, and the left pupil now reacts more slowly to light than the right pupil. Which complication is likely to have occurred? 1. Reperfusion injury 2. Normal stabilization poststroke 3. Increased intracranial pressure 4. Impending brain death
Cotton-wool spots on the retina are an indication of:
A) Macular degeneration. B) Colorblindness. C) Microinfarctions. D) Optic atrophy.