A postpartum patient is developing a thrombophlebitis in her right leg. Which assessment should the nurse make to detect this?
A) Bend the knee and palpate the calf for pain
B) Ask to raise the foot and draw a circle
C) Blanch a toe and count the seconds it takes to color again
D) Dorsiflex the right foot and ask if pain is in the calf
Ans: D
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A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation
The woman should be advised that this condition can best be treated by: a. Running warm water on her breasts during a shower. b. Applying ice to the breasts for comfort. c. Expressing small amounts of milk from the breasts to relieve pressure. d. Wearing a loose-fitting bra to prevent nipple irritation.
Your 16-year-old client is in for an annual physical. During your assessment, he admits to using recreational street drugs at "parties." How should you respond to this admission?
1. Ask nonjudgmental questions about his drug use. 2. Offer to help him find rehabilitation. 3. Call his parents. 4. Pretend he never made the statement.
The patient arrives in the intensive care unit after a bronchoscopy. Which patient assessment is the nurse's priority?
a. Status of the gag reflex b. Level of sedation c. Circulatory status d. Respiratory status
A nurse's most appropriate initial action during the preinteraction phase of a relationship with a homosexual patient should be to:
a. examine personal feelings about homosexuality. b. review the literature that pertains to the human sexual response. c. attempt to identify the underlying reasons for the patient's values. d. focus on a method to assist the patient with changing personal sexual values.