The nurse is observing a client with major burn injuries for signs of Curling's ulcer, a common complication. The nurse should assess the client for:
A)
purulent drainage from wound sites.
B)
frequent headaches.
C)
hypertension.
D)
black, tarry stools.
D
Explanation:
A)
Black, tarry stools would be indicative of GI bleeding from the ulcer. The other options would not be indicative of an ulcer.
Analysis
Implementation
Physiological Integrity: Reduction of Risk Potential
B)
Black, tarry stools would be indicative of GI bleeding from the ulcer. The other options would not be indicative of an ulcer.
Analysis
Implementation
Physiological Integrity: Reduction of Risk Potential
C)
Black, tarry stools would be indicative of GI bleeding from the ulcer. The other options would not be indicative of an ulcer.
Analysis
Implementation
Physiological Integrity: Reduction of Risk Potential
D)
Black, tarry stools would be indicative of GI bleeding from the ulcer. The other options would not be indicative of an ulcer.
Analysis
Implementation
Physiological Integrity: Reduction of Risk Potential
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An older patient who lives with family has a history of chronic alcohol abuse and poor compliance with the medical plan
The patient has begun to experience a marked decline. His family tells the nurse that these problems are a result of their inability to care for the patient properly. The nurse best responds by: a. evaluating the care the family has been providing. b. suggesting that care should be assumed by a professional caregiver. c. helping the family recognize that the de-cline is a result of the patient's condition and personal choices. d. assuring them they are providing the pa-tient with care motivated by love.
The nurse is preparing to examine the external genitalia of a school-age girl. Which of these positions would be most appropriate in this situation?
A) In the parent's lap B) In a frog-leg position on the examining table C) In the lithotomy position with the feet in stirrups D) Lying flat on the examining table with legs extended
Cultural health practices of the African-American client are often considered efficacious, neutral, or dysfunctional. In specific circumstances, the nurse may permit the neutral practice of:
A. Putting a knife under the bed to cut pain. B. Use of sugar and overrefined flour. C. Use of goat's milk and cabbage juice for infection. D. Drinking of a fluid that contains herbs and spices for dehydration.
A middle-aged patient voices concerns about gaining 12 pounds over the past 2 years without changing any dietary habits. Which response by the nurse is most appropriate?
A. "Age-related weight gain can occur because of consistent dietary intake and less physical activity." B. "You might be eating more than you think." C. "You are getting older." D. "Are you exercising?"