Muscle guarding, or tensing of the rectus muscles, during expiration indicates
a. the patient may be anxious. c. possible pyelonephritis.
b. bulging of the aorta. d. possible peritonitis.
D
To determine whether muscle guarding is involuntary, perform light palpation of the rectus muscles during expiration and not muscle tensing. Normally, muscle guarding or tensing of the abdominal musculature is absent during expiration. The patient cannot exercise voluntary muscle tensing during expiration. Involuntary muscle guarding of the rectus muscles suggests irritation of the peritoneum or peritonitis.
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The patient inquires if the new type of gastric analysis is going to require multiple withdrawals of gastric content for evaluation of the presence of hydrochloric acid through-out the day. The nurse replies:
1. "Yes, there will be about 14 in all." 2. "No. You take a dye orally, which will be excreted in the urine in about 2 hours." 3. "Yes. You will take the dye orally and then the several gastric withdrawals will show the dye." 4. "No. Only one withdrawal will be treated with dye and read in about 2 hours."
During the American Civil War, which of the following women was active in the Underground Railroad movement and assisted in leading more than 300 slaves to freedom?
a. Harriet Tubman b. Clara Barton c. Dorothea Dix d. Mary Ann Ball (Mother Bickerdyke)
A school nurse is responsible for teaching adolescents about sexually transmitted diseases (STDs). When discussing chlamydia, the nurse instructs the students that it is:
1. A viral infection that cannot be cured 2. Treated with a full course of antibiotics 3. Contracted via blood-borne exchange 4. Prevented with the use of spermicidals
The nurse is completing the intake and output record for a child admitted for fluid volume deficit. The child has had the following intake and output during the shift: Intake: 4 oz of Pedialyte One-half of an 8-oz cup of clear orange Jell-O Two graham crackers 200 mL of D51/2 sodium chloride IV Output: 345 mL of urine 50 mL of loose stool How many milliliters should the nurse document as the
client's total intake? Give the numerical answer only. Do not include any units of measurement. What will be an ideal response?