A client has numerous petechiae over the face, neck, and upper chest and areas of ecchymosis on the abdomen and upper legs. Which of these skin parameters has the nurse assessed?
a. integrity c. turgor
b. texture d. vascularity
D
Skin normally should be clear with no areas of discoloration. The nurse should note evidence of ecchymosis, petechiae, or telangiectasia.
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When assessing a patient's general appearance, the nurse should include which question?
a. Is the patient's muscle strength equal in both arms? b. Is ptosis or facial droop present? c. Does the patient appropriately respond to questions? d. Are the pupils equal in reaction and size?
The nurse is caring for a patient who was exposed to a high dose of external radiation. What is the least likely nursing action?
A) Assess for and facilitate treatment of life-threatening injuries. B) Assess radiological measurements with a Geiger counter. C) Remove clothing and shower patient as soon as possible. D) Assist in removing penetrating radioactive materials.
A student nurse is instructing a patient restricted to partial weight-bearing on the safe use of crutches. A nurse intervenes when she hears the student say:
1. "If the knee is flexed and the foot is held behind the crutches, it can affect your balance, causing you to fall backward." 2. "Since you are able to bear partial weight on the affected limb, you should use a two-point gait." 3. "Bearing weight on the axilla can cause compression of nerves and can lead to nerve damage affecting the arm and hand." 4. "When walking upstairs on crutches, you should place the affected leg on the step, then move up the crutches and the unaffected leg."
An example of droplet transmission of a disease is by
A) coughing, sneezing, or talking. B) germs carried through the ventilation system. C) microbes carried by moisture and dust in the air. D) inhaling the odor of unpleasant excretions.