A nurse is assessing a patient who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection?
a. Tinnitus, vertigo, and dizziness
b. Clear drainage from the ear and nose
c. Loss of hearing and smell
d. Purulent drainage from the ear and bloody drainage from the nose
ANS: B
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Which of the following is not an environmental factor that affects the nutritional habits of older people?
a. Food storage b. Transportation c. Lack of nutritional knowledge d. Readability of food labels
Which of the following predisposes the pregnant woman to DIC?
a. Diabetes c. Hypertension b. Placenta previa d. Amniotic fluid em-bolism
The parent of your preschool-aged client is concerned that the client is sleeping too much. The client sleeps approximately 11 hours a day
The child has no known physical or psychological problems. Which of the following is the correct response to the parent? 1. "There is no reason to be concerned. It is normal for preschool-aged children to sleep approximately 11 hours each day." 2. "Your child will need further evaluation. It is unusual for preschool-aged children to sleep that much during a 24-hour period." 3. "Are you sleeping about the same amount? If so, your child is picking up sleep patterns from you." 4. "You need to keep a sleep diary and return in a week. I will then have data to help analyze the cause of your child's excessive sleep."
A client says, "I overheard my doctor tell the medical students that I don't have effective immune surveillance. What does that mean?" How should the nurse respond?
1. "I'll get the doctor to come talk to you about what you heard." 2. "I'm certain that the doctor was not talking about you." 3. "Your immune system is not identifying and removing pathogens from your system." 4. "Your body is working against itself."