A nurse is ordered to observe a client suspected to have meningitis for a positive
Brudzinski's sign. What would the nurse document as a positive Brudzinski's sign?
A) Evidence of pain when the client lies on her back and brings one leg up so that the
hip and knee are flexed at 90 degrees
B) Evidence of pain when the client lies on her side and brings one leg up so that the
hip and knee are flexed at 90 degrees
C) Evidence of pain or resistance when the client lies on her back and brings her head
forward toward the chest
D) Evidence of pain or resistance when the client lies on her side and brings her head
forward toward the chest
C
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A patient on the cardiac unit asks the nurse what the first symptoms of mitral stenosis are. When discussing the clinical manifestations of mitral stenosis with this patient, it would be important for the nurse to emphasize what?
A) Palpable arterial pulsations B) New murmur C) Difficulty breathing D) Mitral click
A patient has been on furosemide for the past 2 months. While hospitalized after abdominal surgery, the patient calls for the nurse, stating, "I've gotten very short of breath all of a sudden. I'm having chest pain too."
Which problem would the nurse suspect? 1. Gastroesophageal reflux 2. Stable angina 3. Pulmonary edema 4. Pulmonary embolism
Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports headache? Select all that apply
a. "Describe what the headache feels like?" b. "When was your last eye examination?" c. "What makes the headaches worse?" d. "How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?" e. "Do you have any symptoms with the headaches, such as nausea?" f. "When did you first notice the headaches?"
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest-drainage system. What should the nurse conclude?
A) The system is functioning normally. B) The patient has a pneumothorax. C) The system has an air leak. D) The chest tube is obstructed.