A patient involved in a snowmobile accident struck a tree and sustained a fractured vertebra at C4 . She demonstrates signs of ischemic areas near the injury, along with hypoperfusion, microscopic hemorrhage, and edema
The nurse observes signs of concussion, including loss of consciousness. Which of the following are considered secondary injuries? Select all that apply.
A) Fractured vertebra
B) Cord ischemia
C) Hypoperfusion
D) Microscopic hemorrhage
E) Edema
F) Concussion
A, C, D, E
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The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met?
a. Doing activities of daily living (ADLs) using rest periods b. Helping plan a daily activity schedule c. Requesting a sleeping pill at night d. Telling visitors to leave when fatigued
What should the nurse include in the assessment of muscle strength and movement?
1. Grade the posterior tibial pulses. 2. Grade flaccidity. 3. Observe to see whether strength and movement are bilaterally equal and strong. 4. Percuss the muscle for dullness.
A nurse has an order to take the core temperature of a client. At which of the following sites would a core body temperature be measured?
A) Rectal B) Oral C) Skin surface D) Axillary
During the health history portion of the assessment, the client states, "I have sickle-cell trait." The nurse realizes that:
1. precautions should be taken to prevent the cell from sickling. 2. the client is a carrier. 3. the client will show signs of the disease as she grows older. 4. the client will transmit the disease to any offspring.