The nurse notes that there is an audible clicking sound when the client opens and closes the mouth. What is the appropriate response of the nurse at this time?
a. Recording this as an abnormal finding requiring additional assessment
b. Measuring the distance between each side of the mandible and the eyes
c. Applying resistance to the maxilla and asking the client to repeat the motion
d. Noting this as a normal finding if there are no other associated signs or symptoms
ANS: D
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The nursing student is working with a Latino client who does not speak English. The nursing student speaks only English. Which of the following actions would the student take in order to improve care for this client?
1. Obtain a Spanish/English dictionary and attempt to speak in Spanish. 2. Find an interpreter to help the client and the nursing student communicate. 3. Ask a family member who speaks English to act as the interpreter. 4. Inform the instructor that the client does not speak English, and request a different client assignment.
A patient is diagnosed with atrial fibrillation and the physician orders Coumadin (warfarin). For what skin lesion should the nurse monitor this patient?
A) Ulcer B) Ecchymosis C) Scar D) Erosion
Which of the following suggest that a family health problem may exist? Select all that apply. Family members:
1) Respect each other's need for privacy. 2) Enact decisions made by the most powerful member. 3) Do not consider a conflict resolved until everyone agrees. 4) Set boundaries between family members.
Which of the following contraceptive methods best protects against sexually transmitted infections or HIV?
1. Periodic abstinence 2. Barrier methods 3. Hormonal methods 4. They all protect about the same.