The nurse suspects that a patient has developed a perineal hematoma. What assessment findings would the nurse have detected to lead to this conclusion?
1. Facial petechiae
2. Large, soft hemorrhoids
3. Tense tissues with severe pain
4. Elevated temperature
3
Rationale 1: Facial petechiae do not indicate perineal hematoma.
Rationale 2: Large, soft hemorrhoids are not indicative of perineal hematoma.
Rationale 3: Tenseness of tissues that overlie the hematoma is characteristic of perineal hematomas.
Rationale 4: An elevated temperature can be due to a variety of reasons, such as dehydration or mastitis.
You might also like to view...
A malignant cell is transformed from a normal cell and may begin with a random __________________
Fill in the blank(s) with correct word
What is true about the genetic transmission of sickle cell disease?
a. Both parents must carry the sickle cell trait. b. Both parents must have sickle cell disease. c. One parent must have the sickle cell trait. d. Sickle cell disease has no known pattern of inheritance.
A patient diagnosed with an eating disorder refuses to be weighed and says, "I just drank a big glass of water." Select the nurse's best response
a. "Call me after you have emptied your bladder." b. "This is weight day. Please step on the scale." c. "I will weigh you tomorrow." d. "You know the rules."
The client is just arriving in the postanesthesia care unit following general anesthesia. The nurse's top priority upon receiving the client is to:
1. Assess the client's respiratory status. 2. Assess the client's cardiac status. 3. Ask the client about pain. 4. Assess the client's IV.