A nurse would observe the client for how long to determine whether there is an immediate reaction to a skin test?
a. 1 to 2 minutes
b. 2 to 5 minutes
c. 5 to 10 minutes
d. 10 to 20 minutes
D
Nurses often administer skin tests and interpret test results. An immediate reaction (i.e., appear-ing within 10 to 20 minutes after the injection), marked by erythema and wheal formation greater than 3 mm of the positive control (usually histamine), denotes a positive reaction.
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The perinatal nurse obtains valuable information from a vaginal examination. Which of the following assessments from this examination should the nurse document? (Select all that apply.)
A. Extent of cervical dilation B. Fetal presentation C. Presence of cervical effacement D. Status of the amniotic membranes E. Strength of uterine contractions
A client with chronic myeloid leukemia is admitted to an acute care facility. The nurse understands that the client is least likely to be part of which demographic group?
A. Male B. Younger than 20 years C. Older than 65 years D. Female
A nurse works in a rural community. Concerning the minority population in rural regions, the best action by the nurse is to
a. determine which American Indian tribes are most populous in this area. b. invest in a telephone translation service for different languages. c. learn Spanish and aspects of Hispanic cultural beliefs and practices pertinent to health care. d. investigate specific health care concerns of African Americans in the Midwest.
The nurse on the medical-surgical unit recently received training about identifying and managing risk for violence on the unit. Which client is at the highest risk for exhibiting violent behavior in a clinical setting?
A) A client with the diagnosis of major depressive disorder who refuses to attend groups and unit activities B) A client with a history of violence, admitted with the diagnosis of opioid dependence, but who exhibits no signs of aggression C) A client recovering from hip and knee replacement D) A client who was admitted for gastric bypass operation and is experiencing pain post-surgery