A patient who requires long-term feeding has a surgical endoscopic placement of a feeding tube in the stomach. A nurse correctly identifies this as a
1. Jejunostomy tube (J-tube).
2. Nasogastric (NG) tube.
3. Nasointestinal (NI) tube.
4. Percutaneous endoscopic gastrostomy (PEG) tube.
ANS: 4
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The nurse is reviewing the normal limits of a hearing examination for a patient who presents with decreased hearing. Which of the following findings would indicate the need for additional investigation?
a. Bone conduction is heard twice as long as air conduction with the Rinne test. b. The tympanic membrane observed with the otoscope is pearly gray. c. Sound is heard equally in both ears with the Weber test. d. Words whispered from a distance of 2 feet are repeated by the patient.
Risk assessment for a patient shows these findings
schizophrenia but not acutely psychotic at the moment; not a danger to self or others; lives in parents' home. Which decision regarding placement on the continuum of care is appropriate? a. Hospitalize the patient. b. Discharge the patient from the system. c. Refer the patient to outpatient services. d. Refer the patient to self-help resources in the community.
The nurse is caring for a client with a diagnosed closed head injury that requires intracranial pressure monitoring. Which signs/symptoms indicate that the client's intracranial pressure is rising? Select all that apply.
A. The nurse notes "Doll's eyes" when assessing the client's pupils. B. The nurse documents eupnea in respect to respiratory effort. C. The nurse finds that all extremities are flaccid. D. The nurse notes that blood pressure is stable. E. The nurse documents that the client is in a comatose state.
An infant develops one extremity that is shorter than the other. This occurs with:
A) bone tumors. B) hip fractures. C) loss of calcium. D) hip dislocation.