The nurse is inspecting the tonsils of a client that complaints of a sore throat for size and appearance. What is the appropriate documentation for an observation of tonsils that touch the uvula?
A) 1
B) 2
C) 3
D) 4
C
Feedback:
A scale of 3 is when the tonsils touch the uvula. A 1 is when the tonsils are visible, a 2 is when the tonsils extend medially toward the uvula, and a 4 is when the tonsils touch each other.
You might also like to view...
When using restraints in a long-term-care setting, what ethical dilemma does this pose?
A) Limits personal safety B) Increases confusion C) Threatens autonomy D) Prevents self-directed care
Prior to discharge you determine whether a new mother knows the aseptic method for infant formula and equipment sterilization. Which comment by the mother would indicate that further clarification is needed? (Select all that apply.)
a. "I should wash the equipment in soap and water and place it in a large pan or sterilizer." b. "I should boil the equipment for at least 15 minutes." c. "I can use cold tap water for mixing the formula." d. "When I remove the equipment, I should use tongs." e. " I should mix the formula in the sterilized pitcher." f. "Once I have prepared the formula I should pour it into the bottles, apply lids, and store it in the refrigerator."
The nurse explains that postmortem brain examinations of people with Alzheimer's disease have revealed that there are: (Select all that apply.)
a. tangled nerve cells. b. abnormal buildup of proteins. c. hemorrhagic areas. d. occluded cerebral vessels. e. reduced white matter.
A patient who has inhaled cocaine is admitted to the emergency department with palpitations and shortness of breath. What should the nurse do first?
a. Obtain a 12-lead echocardiogram (ECG). b. Start oxygen at 4 L/minute. c. Draw blood for drug screening. d. Infuse normal saline at 100 mL/hr.