The nurse suspects that a patient has tonsillitis. What did the nurse assess to make this clinical decision?
Select all that apply.
1. hoarse voice
2. thirst
3. nucal rigidity
4. pain around the ears
5. low-grade fever
Correct Answer: 1, 4, 5
Manifestations of tonsillitis include otalgia, hoarse voice, fever, and tender, swollen anterior cervical lymph nodes. Thirst and nuchal rigidity (pain when bending the neck) are not manifestations of tonsillitis.
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A patient is prescribed fluoxetine 20 mg by mouth daily for treatment of depression. The nurse caring for the patient is unfamiliar with this drug. Which action should she take before administering the medication?
1) Inform the prescriber that she is not comfortable administering the drug. 2) Ask a nursing colleague for relevant information about the drug. 3) Consult the drug formulary accessible to staff at the patient care unit. 4) Trust the prescriber writes the dose and administer the drug as intended.
A newly admitted patient is mute, immobile, and holds a fixed body position for long periods. The nurse caring for this patient should
a. assign unlicensed assistance personnel to feed the patient. b. provide a stimulating, active environment. c. encourage independent social behaviors. d. forewarn the patient before touching.
The nurse is caring for a young mother and her children in the free clinic. The client is crying because she lost her job and fears that her child who has asthma may be denied appropriate health care
The nurse realizes that many clients are experiencing these fears and that nurses should: 1. Move to areas needing health care workers. 2. Become involved in professional organizations. 3. Remind clients that everything will be fine. 4. Give clients medications and supplies from the clinic at no charge.
A client approaching middle age asks for information to keep mentally sharp. What should the nurse explain about the cognitive abilities of the middle-aged client?
1. Reaction time stays much the same. 2. Memory is maintained during this time. 3. Learning declines and cannot be completed. 4. Problem-solving ability is maintained during this time. 5. Cognitive and intellectual abilities change very little at this time.