When assessing a patient, the nurse notes a yellow tinge to the patient's skin. The nurse should document that the patient has:
a. dyspnea.
b. cyanosis.
c. jaundice.
d. ecchymosis.
C
Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.
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The nurse receives a referral to visit a client who neighbors fear is being abused by a spouse. The client allows the nurse inside but is obviously reluctant to have the nurse in the home. The nurse could best address the client's concerns by:
(Select all that apply.) 1. Tactfully communicating the reason for the visit. 2. Establishing appropriate expectations for the visit for the client and nurse. 3. Starting to establish a rapport with the client. 4. Stating that the neighbors made the referral. 5. Informing the client that her name has been given to a local women's shelter.
A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital 5 days after her son was circumcised. She is very concerned. On which ra-tionale should the nurse base her reply?
a. After circumcision, the diaper should be changed frequently and fastened snugly. b. This yellow crust is an early sign of infection. c. The yellow crust should not be removed. d. Discontinue the use of petroleum jelly to the tip of the penis.
Select the statement that best explains the potential effect of hyperchloremia in the body.
A. The presence of high levels of chloride causes more hydrogen to be retained in the blood to help balance the excess chloride, causing the development of hyperchloremic acidosis. B. The presence of high levels of chloride causes more hydrogen to be retained in the blood to help balance the excess chloride, causing hyperchloremic alkalosis. C. The presence of high levels of chloride causes more chloride to be absorbed by the renal tubules, leaving less chloride in the extracellular fluid, thereby causing the development of acidosis. D. None of these statements are correct.
The BMI
A. requires complex diagnostic tests that are done only on physicians' orders. B. is calculated to determine the risk of postoperative complications. C. does not go high enough to determine whether a person is morbidly obese. D. reveals whether a person is of normal weight, is overweight, or is obese.