While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action?
a. Have the patient blow the nose until clear.
b. Insert bilateral cotton nasal packing.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears.
C
In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.
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A client with lymphedema of the left leg has a nursing diagnosis of Disturbed Body Image related to lymphedema of the left leg as evidenced by the statement, "I look terrible and am embarrassed to go out
" What intervention can the nurse provide to help this client? A) Inform the client it is acceptable to stay away from social activities. B) Encourage the client to go out and socialize even if he doesn't want to. C) Suggest certain styles of clothing that conceal the enlargement of the leg. D) Refer the client to a psychiatrist.
Which hospitalized patient will the nurse assign to the room closest to the nurses' station?
a. Patient with Alzheimer's disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination
Cognitive function involves which of the following?
a. Muscle movement b. Reasoning and understanding c. Breathing and heartbeats d. The senses and mobility
School-based prevention programs, such as sex education, are MOST likely to succeed when they focus on:
a. moral dictums related to risky behaviors b. social sanctions against risky behaviors c. consequences of risky behaviors d. financial aspects of risky behaviors