A patient who has fallen has superficial abrasions and an abdomen that is distended, firm, and tender when touched. Which complication should the nurse consider that this patient is experiencing?
a. Anaphylaxis
b. Emotional stress
c. Cardiac arrhythmia
d. Internal abdominal bleeding
ANS: D
The shape of the abdomen is observed to detect distention from intra-abdominal hemorrhage. A. Anaphylaxis is associated with an allergic response. B. Emotional stress would not cause the patient's severe abdominal symptoms. C. A cardiac arrhythmia would not cause the patient's abdominal symptoms.
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What is the term used in the nursing process for the patient's problem?
a. Patient data b. Nursing diagnosis c. Nursing intervention d. Outcome planning
A parent reports that his 7-year-old child is very short compared to his peers, and his teeth came in slowly when he was younger. After searching the Internet the parent is worried about growth hormone deficiency (GHD)
Which response by the nurse is the most appropriate? A. "GHD is the only cause of the symptoms you describe." B. "Has your child ever had his thyroid evaluated?" C. "I will refer your child to an endocrinologist right away." D. "What did the dentist say about his teeth being delayed?"
The nurse has provided patient teaching for a patient who will be discharged to home on an anti-infective. What statement made by the patient indicates the nurse needs to provide additional teaching concerning the use of anti-infectives?
A) "Antibiotics will not help me when I have a viral infection." B) "A bacterial culture will be done before antibiotics are prescribed for me." C) "I could develop diarrhea as a result of taking an antibiotic." D) "I will stop taking the antibiotic as soon as I feel better."
The nurse is assessing a patient for a possible conductive hearing loss. What should the nurse perform first?
1. external ear exam 2. Weber test 3. Rinne test 4. tympanogram