The nurse is assessing the skin of a client being admitted to the long-term care facility from an acute care facility. A small blister is noted on the client's right heel. This is documented as:
1. A stage I decubitus ulcer.
2. A stage II decubitus ulcer.
3. A stage III decubitus ulcer.
4. A stage IV decubitus ulcer.
2
Rationale: A stage I ulcer is a nonblanchable redness of intact skin.
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The client has been a victim of a violent, sadistic rape. She is crying, and asks the nurse "Why would someone do something like that?" The nurse should explain that which of the following is the primary purpose of sadistic rape?
1. Take pleasure from the victim's struggle and pain 2. Express feelings of rage 3. Feel a sense of power or mastery 4. Relieve intolerable anxiety
Activation of the humoral immune system by an antigen results in the production of which substance?
1. Immunoglobulins (antibodies) specific for the antigen 2. Macrophages specific for the immunogen 3. Sensitized T lymphocytes 4. Sensitized natural killer (NK) cells
A nurse is caring for a patient who just underwent an intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient?
a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Monitor the patient for fever, rash, and difficulty breathing. d. Administer narcotic medications to the patient for pain.
A nurse auscultates a client's hear rate and rhythm and finds the rhythm to be irregular. Which of the following would the nurse do next?
A) Inspect for a lift B) Palpate for a thrill C) Auscultate for pulse rate deficit D) Listen for a ventricular gallop