The nurse knows that during an abdominal assessment, deep palpation is used to determine:
a. Bowel motility.
b. Enlarged organs.
c. Superficial tenderness.
d. Overall impression of skin surface and superficial musculature.
ANS: B
With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.
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A highly suicidal patient who has been hospitalized for 2 weeks committed suicide during the night. The measure that will be helpful to staff and patients having to deal with the event is:
a. asking the patient's roommate not to discuss the event with other patients. b. keeping newspapers off the unit and sending the television "out for repair.". c. holding a staff meeting to express feelings and plan care for other patients. d. discharging the other patients as quickly as possible to prevent copycat attempts.
A 4-year-old boy has a febrile seizure during a well-child visit. Which of the following would be a priority?
A) Hyperextending the child's head while placing him on his side B) Using a tongue blade to pry open the child's jaw C) Loosening the child's clothing to ensure a patent airway D) Protecting the child from harm during the seizure
What is the best predictor that a hypertension patient will comply with a newly prescribed low-sodium diet?
a. The amount of knowledge about the patient has of the diet. b. The amount of distress the patient has about his illness. c. The patient's previous ability to lose 15 lbs. through following a weight reduction program. d. The patient's desire to not suffer from hypertensive complications.
The nurse is working with a patient on an inpatient hospice unit. To demonstrate caring and maintain the patient's sense of self-worth during the end of life, the nurse should:
A) leave the patient alone to deal with final affairs B) call upon the patient's spiritual advisor to take over care C) plan regular visits throughout the day D) have a grief counselor visit