A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault
The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of:
A) Increasing intracranial pressure (ICP)
B) An epidural hematoma
C) Leakage of cerebrospinal fluid (CSF)
D) Meningitis
C
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The nurse is evaluating the goals and outcomes of a patient with mental illness. What is the purpose of a patient-specific outcome?
1. It guides the nurse to the appropriate nursing diagnosis. 2. It guides the nurse to the appropriate nursing interventions. 3. It allows the nurse to define the particular steps made toward improved health. 4. It allows the nurse to perform a focused assessment based on the particular outcome.
The nurse is assessing a client with overnutrition. Which question should the nurse ask the client?
A. "Do you take multiple medications?" B. "Are you allergic to any foods?" C. "Do you have access to adequate amounts of food?" D. "Are you taking dietary supplements?"
The nurse has provided education for a client prescribed topical scabicide. Which statement made by the client indicates an understanding of the teaching?
A. "I will monitor the area daily for the next few weeks." B. "I can expect some redness to occur." C. "I need to sign a consent for this medication." D. "I will leave the treatment on longer to make sure it is effective."
When conducting nasotracheal suctioning of a client, what will the nurse do?
1. Apply suction for 5–10 seconds. 2. Plan to suction for 10 minutes. 3. Apply suction while inserting the catheter. 4. Apply suction for 20–30 seconds.