A 35-year-old client with a cervical injury is provided with a halo device to stabilize the
neck. What measures must the nurse employ when caring for a client with skull tong
traction?
A) Place the client in an antidecubitus bed if possible
B) Tighten the halo device with a wrench if it loosens
C) Monitor the client for any difficulty in swallowing
D) Instruct the client to stay in bed until the injury heals
C
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The posterior surface of the prostate can be located by palpation of the:
a. anal canal and perineum. b. anterior wall of the rectum. c. lateral wall of the anus. d. lower abdomen and perineum.
When caring for a client who has received a mydriatic medication, the nurse should:
a. Instruct the client not to drive until the medication wears off. b. Assess the client for glaucoma and cataracts. c. Instruct the client to keep eyes closed for six hours. d. Encourage the client to wear sunglasses.
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
a. The patient takes insulin daily. b. The patient states that the ulcers are very painful. c. The patient has had the heel ulcers for the last 6 months. d. The patient has several old incisions that have formed keloids.
The nurse is providing care to a child who is nearing death. Which nursing actions may offer the family support?
1. Using active listening techniques 2. Looking the parents in the eye when talking 3. Refusing to cry while in the child's room 4. Offering to call and notify family 5. Avoiding being in the room to allow the family to grief