Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site?
a. Apply a warm compress.
b. Massage the site in a circular motion.
c. Apply a soothing lotion.
d. Have the client assume a sitting position.
ANS: D
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The nurse is caring for a client with bilateral rales audible in the bases of the lung, jugular vein distention, and a low hematocrit. The nurse attributes these symptoms to which of the following?
1. Fluid volume deficit 2. Fluid volume balance 3. Fluid volume excess 4. Elevated serum calcium and magnesium levels
A 25-year-old primigravida is 20 weeks pregnant. At the clinic, her nurse begins a prenatal assessment and obtains the following vital signs. Which finding would require the nurse to contact the physician?
1. Pulse 88/min 2. Respirations 30/min 3. Temperature 37.4°C (99.3°F) 4. Blood pressure 134/82
P.M., a 24-year-old house painter, has been too ill to work for the past 3 days. When he arrives at youroutpatient clinic with his girlfriend, he seems alert but acutely ill, with an average build and a deep tanover the exposed areas of skin
He reports headaches, joint pain, a low-grade fever, cough, anorexia, and nausea and vomiting (N/V), especially after eating any fatty food. P.M. describes vague abdominal pain that started about the same time as the other problems. He states that he has been using "a lot of Tylenol" for his pain. His past medical history reveals he has no health problems, is a nonsmoker, and drinks "a few" beers each evening to relax. Vital signs are 128/84, 88, 26, 100.6 ° F (38.1 ° C); awake, alert, and oriented× 3; moves all extremities well with complaints of aching pain in his muscles; very slight scleral jaundice present; heart and breath sounds clear and without adventitious sounds; bowel sounds clear throughout abdomen and pelvis; and abdomen soft and palpable without distinct masses. You note moderate hepatomegaly measured at the midclavicular line; liver edge is easily palpated and tender to palpation. P.M. mentions that his urine has been getting darker over the past 2 days. Your institution uses electronic charting. Based on the health history and assessment described in the scenario, which of the following systems would you mark as "abnormal" as you document your findings? Mark abnormal findings with an X and provide a brief narrative. X Abnormal ? Neurologic: ? Respiratory: ? Cardiovascular: ? Gastrointestinal: ? Genitourinary: ? Musculoskeletal: ? Skin: ? Pain: ? Neurologic: Awake, alert, and oriented× 3. ? Respiratory: Reports cough; breath sounds clear and without adventitious sounds. ? Cardiovascular: Heart sounds clear and without adventitious sounds. ? GI: Bowel sounds clear throughout abdomen and pelvis; and abdomen soft and palpable without distinct masses. Hepatomegaly measured at the midclavicular line; liver edge is easily palpated and tender to palpation. Complains of (C/O) vague abdominal pain, anorexia, and N/V, especially after eating any fatty food. ? Genitourinary: States that his urine has been getting darker over the past 2 days. ? Musculoskeletal: Moves all extremities well. C/O aching pain in his muscles and joint pain. ? Skin: 100.6° F (38.1° C). Very slight scleral jaundice present. ? Pain: Reports headaches P.M. is manifesting key signs of hepatitis. Laboratory work is requested for identification of his precise problem. Which key diagnostic tests will determine exactly what type of hepatitis is present?
Which of the following statements regarding hepatitis A virus infection (HAV) is INCORRECT?
A. It is transmitted by fecal contamination of food or water supplies. B. Recovery confers immunity to subsequent HAV infection. C. HAV infection becomes chronic in many infected persons who become chronic carriers of the virus and may develop chronic hepatitis. D. It may be transmitted by anal-to-oral and/or oral-to-genital sexual practices.