The nurse is caring for four clients with different diagnoses. Which diagnosis cues the nurse to shave the client with an electric razor?
1. Hypertension
2. Diabetes mellitus
3. Closed head injury
4. Pulmonary embolus
4
4. A client with a pulmonary embolus (PE) receives anticoagulant therapy to prevent the formation of additional emboli and to allow autodigestion of the PE; the nurse avoids shaving clients receiving anticoagulants with a razor to prevent prolonged bleeding of potential facial cuts from the razor.
1, 2, and 3. Hypertension, diabetes mellitus, and a closed head injury are unlikely to require precautions for prolonged bleeding caused by anticoagulation. Anticoagula-tion is not indicated for hypertension, usually, and is contraindicated for a closed head injury. If the client's brain bleeds, intracranial pressure increases and potentially results in a devastating, life-threatening injury.
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A 79-year-old man is being assessed for age-related macular degeneration (AMD) and will be taught strategies for self-assessing changes in visual acuity. This patient should be:
A) Provided with a Snellen chart and taught to use it correctly B) Given an Amsler grid and encouraged to use it several times a week C) Provided with a prescription for pilocarpine hydrochloride (Isopto Carpine) D) Encouraged to read books and magazines with a small font size
What factor is most important in predisposing toddlers to frequent infections?
a. Respirations are abdominal. b. Pulse and respiratory rates in toddlers are slower than those in infants. c. Defense mechanisms are less efficient than those during infancy. d. Toddlers have short, straight internal ear canals and large lymph tissue.
A client is admitted to the telemetry unit. Which of the following nursing assessments would have the highest priority for further investigation?
1. The client complains of intermittent chest pain during mild exercise. 2. The client's father has a history of smoking. 3. The client has a history of urinary retention. 4. The client complains of fatigue and dyspnea after walking up several flights of stairs.
Routine infant and childhood screenings should include all of the following except
1. Body measurement (height, weight, head circumference). 2. Depression screening. 3. Developmental screening. 4. Infant screenings (phenylketonuria [PKU], hypothyroidism). 5. Lead screening.