A patient is admitted with severe facial injuries from a motor vehicle crash. For what should the nurse first assess this patient?
1. signs of stridor, cough, or respiratory distress
2. blood pressure
3. need for suctioning
4. loose teeth or obvious problems with the mouth
Correct Answer: 1
The patient with multiple injuries is at great risk for developing airway obstruction and apnea. All of the choices are important; however, the most important assessment is for a patent and maintainable airway. The nurse should assess for manifestations of airway obstruction including stridor, tachypnea, bradypnea, cough and cyanosis, dyspnea, decreased or absent breath sounds, changes in oxygen levels, and changes in level of consciousness. After it has been determined that the airway is adequate, the blood pressure and mouth can be assessed and the need for suctioning determined.
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A client who experienced a severe head injury is demonstrating a lack of response to painful stimuli, pupils are unequal and fixed, and decorticate posturing. The nurse takes immediate steps, as the client is experiencing:
1. disorientation. 2. early increased intracranial pressure (IICP). 3. a subdural hematoma. 4. signs of late IICP.
The nurse notes that the patient's tympanic membrane (TM) is golden brown. There is thick, elastic drainage noted as well. Which conclusion by the nurse is accurate?
1) The patient has scar tissue from a previous ruptured TM. 2) The patient has bleeding as a result of trauma. 3) The patient is experiencing a complication of chronic otitis media. 4) The patient is experiencing adhesive otitis media.
A researcher finds that a small number of subjects did not provide accurate information because they had just completed a rigorous session with the physical therapist. This is an example of:
A) Sample bias B) Systemic bias C) Random bias D) Absolute bias
A pregnant client calls the nurse at the physician's office and reports that she has noticed a thin, colorless, vaginal drainage. Which of the following information would be most appropriate for the nurse to provide to the client?
1. Come to the clinic immediately. 2. Report to the emergency department at the maternity center immediately. 3. The vaginal discharge may be bothersome but is a normal occurrence. 4. Use tampons if the discharge is bothersome but be sure to change the tampons every 2 hours.