The nurse documents which sign(s) of epidural hematoma in a patient with a closed head injury? (Select all that apply.)
a. Mottling of extremities
b. Periorbital ecchymosis
c. Battle sign
d. Nausea and vomiting
e. PERRLA
B, C, D
Raccoon eyes (periorbital ecchymosis), bruising behind the ears (Battle sign), and nausea and vomiting are some of the typical signs of epidural hematoma.
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Which assessment by an emergency department nurse most indicates that a burn patient might be at risk for respiratory impairment?
a. Burns on the face and neck b. Respiration of 18 breaths/min c. Flaring nares d. Sooty sputum
The nurse is assessing the cardiovascular status of a client who was found unresponsive in a lobby area. Following transfer of the client, the family asks how blood circulates through the body
The nurse is most correct to state the proper circulation as which? Place the pattern of circulation in the correct order beginning in the right atrium. Use all options. A) Pulmonary vein B) Right ventricle C) Left ventricle D) Pulmonary artery E) Left atrium F) Aorta
The nurse is aware that an acoustic neuroma is a:
A) Tumor of cranial nerve VI B) Fast-growing tumor C) Tumor of cranial nerve VII D) Tumor treated primarily with surgery
The nurse is assessing for hepatojugular reflux in a patient with a history of heart failure. When performing this assessment, the nurse will:
A) Elevate the patient's head to 90 degrees B) Press the patient's right upper abdomen C) Palpate the patient's jugular veins simultaneously D) Lay the patient flat in bed