The nurse is auscultating the fifth intercostal space left midclavicular line. Which should the nurse anticipate documenting?
A. Aortic sounds.
B. Tricuspid sounds.
C. Pulmonic sounds.
D. Apical pulse.
Answer: D
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Muscle spasticity is noted upon nursing assessment in a spinal cord-injured patient. The nurse would expect which of the following medications to be ordered to control this clinical manifestation?
A) Baclofen (Lioresal) B) Dexamethasone (Decadron) C) Mannitol (Osmitrol) D) Phenobarbital (Luminal)
When palpating a patient's liver, the nurse feels a firm edge. What would this indicate to the nurse?
A) Cirrhosis B) Liver failure C) Calcification of the liver D) Splenomegaly
A client diagnosed with dissociative identity disorder (DID) switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function?
A. It is a means to attain secondary gain. B. It is a means to explore feelings of excessive and inappropriate guilt. C. It serves to isolate painful events so that the primary self is protected. D. It serves to establish personality boundaries and limit inappropriate impulses.
What is the most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation?
a. Oral thermometer b. Rectal thermometer c. Temporal thermometer scan d. Tympanic membrane sensor