Which clinical manifestations would the nurse expect to observe in a client with a grade III open fracture?
A. An open fracture with minimal skin damage
B. A 6- to 8-cm wound with damage to skin, muscle, and nerve tissue
C. An open fracture accompanied by skin and muscle contusions
D. Internal damage to skin, muscle, and nerve tissue, but no open wound noted
B
An open or compound grade III fracture is the most severe. The client may have a 6- to 8-cm wound with damage to skin, muscle, nerve tissue, and blood vessels.
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A teen comes to the school nurse to get help with anxiety about singing in front of the school. The teen states, "I just know everyone is going to laugh
What if I sing off-key?" What does the nurse recognize as the teen's source of anxiety? 1. Unmet expectations important to self-integrity 2. Inability to gain or reinforce self-respect from others 3. Discrepancies between self-view and actual behavior 4. Anticipated disapproval by significant others
The nurse is selecting a peripheral infusion device for insertion. The scalp vein needle is most appropriate for: Standard Text: Select all that apply
1. Single-dose therapy. 2. Delivery of blood. 3. Long-term peripheral IV therapy. 4. Transplant clients. 5. Clients allergic to nylon or Teflon.
During a physical exam, the nurse notes that the patient has a smooth red tongue. Which of the following diagnostic tests is an expected follow-up?
A) Biopsy any lesions. B) Scrape the tongue for syphilis. C) Screen for lead poisoning. D) Complete a nutrition screening.
When determining which patient has the priority to be assessed first, the nurse should always evaluate the patient who is:
a. unstable c. on the ventilator b. having pain d. receiving blood