You record that J.T.'s fingers are warm with capillary refill in less than 2 seconds. Sensory perception is
intact. He is able to flex and extend the distal joints but not the proximal joints of the third and fourth
fingers.
He rates his pain as a 5 out of 10.
You notice J.T.'s wedding band and promptly ask him to remove it. Why is this important?
What will be an ideal response?
The wedding band needs to be removed as quickly as possible before there is further swelling of the
finger. Rings can compromise circulation to an edematous digit.
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A mother is worried that her 3-month-old child is not holding her own head up. Which action by the nurse is most appropriate?
A. Explain that sturdy head control occurs around 6 months. B. Document the findings and alert the health-care provider. C. Reassure the mother that her baby is completely normal. D. Teach the mother that head control is evident at 9 months.
A patient comes into the emergency department with itching, swelling, and slight shortness of breath after being stung by a bee 20 minutes ago. The nurse bases care of this patient on the pathophysiology of which hypersensitivity reaction?
1. Type I IgE-mediated hypersensitivity 2. Type II cytotoxic hypersensitivity 3. Type III immune complex-mediated hypersensitivity 4. Type IV delayed hypersensitivity
Assuming all the following are staff members on the unit, to whom should the LPN/LVN charge nurse assign a newly admitted 65-year-old resident with left hemiplegia and a large sacral decubitus requiring a sterile dressing change?
a. LPN/LVN orientee with 1 week of experience b. LPN/LVN with 2 years of experience c. Nursing assistant with 3 years of experience d. Nursing assistant who is a nursing student at a local college
Psychosocial reasons for the increase in incidence of sexually transmitted diseases in the teen population include:
a. Teens are marrying earlier b. Teens are maturing later c. Teens tend to have one sexual partner d. Teens are having intercourse at a younger age