The nurse has provided basic information to a client about the kidneys. Which of the following client statements would indicate that additional instruction would be needed?
1. "A person cannot survive without both kidneys."
2. "The kidneys are approximately 4.5 inches long."
3. "The kidneys are positioned in the retroperitoneal space."
4. "The right kidney is lower than the left."
1
The client statement that would indicate the need for more instruction is "a person cannot survive without both kidneys." A person can easily survive with a single kidney. The other client statements would not indicate the need for additional instruction.
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The nurse is caring for a client requiring mechanical ventilation who is deeply sedated and receiving paralytic medications. Which nursing intervention would assist the client to optimize oxygenation?
1. Hyperventilating the client once an hour 2. Hyperoxygenating the client once an hour 3. Encouraging coughing and deep breathing 4. Frequent repositioning
During your assessment of a patient for doll's eyes phenomenon, you observe that the patient's eyes remain fixed. This response most likely indicates
a. a normal finding. c. injury to cranial nerves III, IV, and VI. b. damage to the lower brainstem. d. hematoma formation behind his eyes.
During a follow-up visit, the health care
provider examines the fundus of the patient's eye. Afterward, the patient asks the nurse, "Why is he looking at my eyes when I have high blood pressure? It does not make sense to me!" What is the best response by the nurse? a. "We need to monitor for drug toxicity." b. "We must watch for increased intraocular pressure." c. "The provider is assessing for visual changes that may occur with drug therapy." d. "The provider is making sure the treatment is effective over the long term."
Mr. McDonnel is a 29-year-old patient who presents to the office with complaints of enlarged lymph nodes just inferior to the chin. Nodes that are palpable just inferior to the chin are the ______________ nodes
a. infraclavicular b. submental c. submandibular d. parotid