A client presents with purulent, bloody drainage of the ear. Which of the following would the nurse assess first?
A) Assess the tympanic membrane.
B) Ask whether there is any pain in the ear.
C) Inspect the external ear canal.
D) Ask whether the client has experienced any hearing loss.
C
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A middle-aged parent goes to the emergency room for symptoms of dizziness, headache, and suicidal ideation
The nurse assesses the patient for substance use, employment, child-rearing stressors, relationships with coworkers, recurring physical symptoms, and marital problems. The nurse is: 1. Failing to focus on the seriousness of the primary presenting problem. 2. Establishing rapport that will decrease the likelihood of suicide. 3. Doing more than the nurse's share of the interdisciplinary assessment. 4. Formulating a holistic–interactional assessment needed to interpret clinical data.
A nursing student asks a nurse why a patient in hypertensive crisis is receiving both intravenous sodium nitroprusside [Nitropress] and oral hydralazine. The nurse will explain that this is done to prevent:
a. cyanide poisoning. b. fluid retention. c. rebound hypertension. d. reflex tachycardia.
The nurse working with a post-transplant client tells the client that he should refrain from returning to his distant original home for up to
a. 1 week. b. 8 weeks. c. 3 months. d. 6 months.
The nurse is caring for a child with severe head trauma after a car accident. Which is an ominous sign that often precedes death?
a. Papilledema b. Delirium c. Doll's head maneuver d. Periodic and irregular breathing