The nurse instructs a woman taking oral contraceptives to report which possible side effects? (Select all that apply.)
a. Abdominal pain
b. Weight gain
c. Headache
d. Eye or visual problems
e. Speech disturbances
ANS: A, C, D, E
The memory aid ACHES is helpful: Abdominal pain, Chest pain, Headaches, Eye problems, Speech disturbances. Weight gain is an expected side effect of oral contraceptives.
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The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen.
Level one interventions for potentially assaultive clients should be practiced as:
a. Therapy b. Control methods c. Assessment measures d. Preventive measures
The nurse suspects that an older client is experiencing dehydration. Where should the nurse assess skin turgor on this client?
1. Abdomen 2. Upper extremities 3. Sternum 4. Lower extremities
The nurse assisting with the oculovestibular response (OVR) test on a client recognizes that the brain stem is intact when the client's eyes
a. demonstrate sustained nystagmus. b. do not deviate with the instillation of ice water. c. rapidly move toward the ear irrigated with warm water. d. slowly move toward the ear irrigated with ice water.