Which assessment finding would suggest to the nurse that the school-age patient is experiencing psychological abuse?
1) Dressing provocatively
2) Complaining of genital itching
3) Exhibiting poor social skills
4) Earning honor roll at school
ANS: 3
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The patient accidentally discards voided urine during a 24-hour urine collection. What should the nurse do next?
a. Instruct the patient to call for help before voiding. b. Consult with the laboratory for further instructions. c. Discard all urine and begin another 24-hour collection. d. State on the laboratory requisition that one specimen is missing.
The nurse caring for a female patient 1 day after a thoracotomy assesses that the patient is in pain, but the patient states that she has no pain. Which does the nurse use to confirm the patient's pain?(Select all that apply.)
a. Facial grimacing during linen changes b. Eats a full liquid diet without assistance c. Uses the incentive spirometer every hour d. Patient's culture forbids complaints of pain e. Has received nothing for pain since sur-gery f. Heart rate 110, blood pressure 169/90
The client was born without arms. Which artery does the nurse use to measure the client's blood pressure?
1. Ulnar 2. Carotid 3. Brachial 4. Popliteal
A client having an abdominal resection also has a history of myasthenia gravis. Due to the risk of nitrous oxide, what does the nurse anticipate this client to be at a greater risk for developing?
1. Increased intracranial pressure and respiratory depression 2. Nausea and vomiting during surgery 3. Increased cranial pressure and vomiting 4. Respiratory depression and prolonged hypnotic effects