The nurse observes drainage from a client's ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. Which description of the fluid supports the nurse's suspicion?
1. Yellow without sediment.
2. Blood-tinged without sediment.
3. Clear, colorless.
4. Pink without sediment.
Correct Answer: 3
It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Yellow drainage, blood-tinged fluid, and pink drainage without sediment are not consistent with cerebral spinal fluid.
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A nurse and his girlfriend witness a motor vehicle accident. The calls 911 and pulls over to the side of the road. The nurse assesses the victim and determines that he is unconscious. His girlfriend says, "This guy can't give you permission to help him;
maybe you should just leave him alone." The nurse explains that he has implied consent. When is implied consent assumed? A. At the time a person sees a physician or nurse by appointment in the office or clinic setting B. When a person arrives in the operating suite for a surgical procedure. C. On the person's admission to the hospital unit. D. If the person is treated at the scene of an accident
A nurse who works at an outpatient mental health clinic follows numerous clients who have schizophrenia, many of whom are being treated with olanzapine (Zyprexa)
Which of the following clients likely has the highest susceptibility to the adverse effects of olanzapine? A) A client who is morbidly obese and who has a sedentary lifestyle B) A client who has type 1 diabetes and who practices poor glycemic control C) A client who has a body mass index of 16.5 (underweight) and who smokes one pack of cigarettes daily D) A client who was recently treated with intravenous antibiotics because of cellulitis in his lower leg
Which action is MOST important when a nurse is caring for a client who has leukemia?
a. following proper hand hygiene b. providing frequent oral care with a soft toothbrush c. encouraging the client to talk about fears and concerns d. administering prescribed vitamins and antiemetics
Which of the following provides an effective means of researching primary research in a logical and systematic manner, providing a more efficient and effective means to find credible scientific information than if one were doing a general Web
search? 1. Wikis 2. Systematic literature searches 3. Blogging 4. Telehealth