The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?
a. Cleanse nose with a soft cotton-tipped swab
b. Gently suction the nasal cavity
c. Gently wipe nose with absorbent gauze
d. Ask patient to blow his nose
ANS: C
The patient's ear and nose are checked carefully for signs of blood and serous drainage, which indicate that the meninges are torn and spinal fluid is escaping. No attempt should be made to clean out the orifice or to blow the nose. The drainage can be wiped away. The drainage can be tested for the presence of glucose, which would confirm that the fluid is spinal fluid and not mucus.
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When a toddler attempts to feed himself, the family should:
a. encourage the child to use a fork. b. feed the child themselves using a fork. c. encourage large portions for easier handling. d. offer the child finger foods.
An older male patient with benign prostatic hypertrophy (BPH) is experiencing an increase in symptoms. Which finding would explain the reason for this patient's change in symptoms?
1. Recent vasectomy 2. Decreased oral intake at night 3. Use of over-the-counter saw palmetto 4. Use of over-the-counter cold medication
A woman tells the nurse at a prenatal interview that she has quit smoking, only has a glass of wine with dinner, and has cut down on coffee to four cups a day. What response by the nurse will be most helpful in promoting a lifestyle change?
a. "You have made some good progress toward having a healthy baby. Let's talk about the changes you have made." b. "You need to do a lot better than that. You are still hurting your baby." c. "Here are some pamphlets for you to study. They will help you find more ways to improve." d. "Those few things won't cause any trouble. Good for you."
A patient tells the nurse that he does not understand the surgical procedure the health care provider told him he needed. Which of the following should the nurse do to advocate for this patient?
1. Contact the health care provider and ask that the procedure be explained to the patient. 2. Explain the procedure to the patient. 3. Document that the patient does not understand the proposed surgical procedure. 4. Instruct the patient in alternatives to the surgical procedure.