While assessing the ears of an 8-year-old client, the nurse observes white spots on the tympanic membrane with no redness present. Which action would be most appropriate?
A) Assess the client for trauma to the skull.
B) Determine whether impacted cerumen is present.
C) Ask the mother whether the child has had numerous ear infections.
D) Assess the child for further symptoms of acute otitis media.
C
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The nurse plans to give a client written materials as a part of the educational plan. Which observation by the nurse indicates that this is an appropriate form of learning material for this client?
a. Client has frequent visitors. b. Client spends quiet time reading. c. Client spends quiet time watching television. d. Client spends quiet time listening to the radio.
To assess the tonic neck reflex of a 3-month-old infant in a supine position, you rotate the infant's head to the right side and hold the jaw parallel to the shoulder. A normal response is for the infant to
a. extend both arms. c. flex both legs. b. extend the left arm and leg. d. flex the left arm and leg.
With the uncertainty that a multiple trauma accident poses in an Emergency Department, the physicians and nursing staff generally tend to come together for the "common good
" This is il-lustrated by which of the following communication strategies? A. Less enthusiasm and frantic, quick state-ments of doom B. Somber tone with short, monosyllabic words C. More professional wording and less fami-liarity with team members D. More personal and group approach
The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation, how should the extremity feel?
1. Cool, with a capillary refill of greater than 3 seconds 2. With a palpable dorsalis pedis pulse but an absent posterior tibial pulse 3. Decreased sensation, with an absent dorsalis pedis pulse 4. Warm, with a capillary refill less than 3 seconds