The patient has delivered a 4200g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The patient asks the nurse where she tore. Which response is best? "The episiotomy extended and tore:
1. "Through your rectal mucosa."
2. "Up near your urethra."
3. "Into the muscle layer."
4. "Through your rectal sphincter."
4
Rationale 1: A fourth-degree laceration is through the rectal mucosa.
Rationale 2: A periurethral laceration is near the urethra.
Rationale 3: A first-degree laceration involves only the skin. A second-degree laceration involves skin and muscle.
Rationale 4: A third-degree laceration includes the rectal sphincter.
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The unlicensed nursing assistive person (UAP) reports to the nurse that a patient is crying during a comedy show on television. The nurse's best response should be:
a. "Maybe the patient doesn't think the show is funny." b. "Don't worry about it. Her daughter says this is normal." c. "I will go visit her right away and see what is going on." d. "Just document what you observe in your notes."
As a nurse manager, you identify that a shift in nursing care models might increase patient and staff satisfaction and avoid downsizing. Administration is reluctant to adopt this approach be-cause downsizing is seen as critical to reduction of costs
To leverage your ideas, you: a. Ask staff to send e-mails to administration encouraging consideration of your option. b. Invite a senior member of administration to your staff meeting, so you can tell him what you are planning. c. Write a letter of complaint to a member of the institutional board about the lack of openness of the administration. d. Identify influential members of your nurse manager group with similar ideas and re-quest an opportunity to meet with admin-istration to discuss options.
A patient with a sore throat is complaining of "trouble with hearing." The nurse realizes that this patient might be experiencing:
1. a sinus infection. 2. a middle ear infection. 3. infected tonsils. 4. an inner ear infection.
The nurse is instructing a client about the timing of ovulation during the menstrual cycle. While reviewing the laboratory analysis of the client's hormones, the nurse would examine for increases in which of following levels?
1. Luteinizing hormone 2. Progesterone 3. Estrogen 4. Gonadotropin-releasing hormone