A confused patient has been restrained because of combativeness and hyperactivity. What skin assessment may occur as a result of the restraints?
a. Lentigines
b. Senile purpura
c. Senile angiomas
d. Seborrheic keratoses
B
Purpura are purple bruises that resolve very slowly and are usually the result of minor trauma.
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The nurse is performing perineal care for the uncircumcised patient. Which of the following is true?
a. The foreskin should not be moved. b. The foreskin should be retracted, pulling it away from the body. c. The foreskin should be left retracted and allowed to return to position naturally after care. d. The foreskin should be retracted and returned to position by the nurse after cleaning, rinsing, and drying.
The nurse is performing an assessment of a patient's musculoskeletal system and is appraising the patient's bone integrity. What action should the nurse perform during this phase of assessment?
A) Compare parts of the body symmetrically. B) Assess extremities when in motion rather than at rest. C) Percuss as many joints as are accessible. D) Administer analgesia 30 to 60 minutes before assessment.
The nurse is preparing to assess the client's blood pressure using an electronic monitoring unit and notices that the end of the cord is frayed. Which action by the nurse is most appropriate to prevent harm?
A) Plug the machine in to make sure it works appropriately. B) Get another machine from the equipment room. C) Label the machine as broken and notify engineering. D) Complete an incident report.
The client has received an injection of a small amount of anesthetic drug into the skin and subcutaneous tissues surrounding a cut. This is an example of:
a. epidural anesthesia c. nerve block b. local anesthesia d. spinal anesthesia