The nurse is assessing a patient's skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation?
a. Burn
b. Laceration
c. Pressure ulcer
d. Infection
ANS: C
A major manifestation of impaired skin integrity is a pressure ulcer.
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The nurse who assesses for cultural influences, values cultural diversity, and incorporates cultural knowledge in practice is said to be ____________ _____________
ANS:
A client at the end of life has an antimuscarinic medication ordered for secretion management. When is the ideal time for the nurse administer this medication?
A) At the first sign of the death rattle B) When the death rattle can be heard from several feet away C) Before the death rattle occurs D) If the death rattle upsets the family
The nurse is performing a focused interview with the client. The nurse asks the client if the client has noticed any drainage from the ears, and the client states, "Yes."
Which of the following statements indicate that the client may have developed acute otitis media? 1. "The ear canal itself is really red, raw, and sore.". 2. "I noticed that the drainage looked clear, like water.". 3. "The drainage looks like what is draining from my nose, kind of clear and mucousy.". 4. "It is kind of yellowish-reddish color.".
A nurse is working with an outreach group to educate the public regarding influenza immunization. Which groups should this nurse target?
Standard Text: Select all that apply. 1. Residents of long-term care 2. Health care providers 3. Healthy young males 4. Women who will be pregnant during influenza season 5. Children with asthma