Mary Jane has brought in her 16-year-old son, Kyle. She states that he has been sleeping more and does not hang around his friends, and recently his girlfriend broke up with him. Your most immediate question is to ask Kyle:
a. "Do you want to see a counselor today?"
b. "Is your father out of jail yet?"
c. "Are you taking any illegal drugs?"
d. "Have you made plans to harm yourself?"
D
If you sense that a patient is contemplating suicide, you should ask about suicidal ideation di-rectly. The most important area to address is the potential for suicide. The question "Is your fa-ther out of jail yet?" may be relevant to the history, but is not an immediate concern.
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The patient arrives in clinic for a 2-month follow-up appointment following chemotherapy. The nurse notes that the patient's skin appears yellow. What blood tests should be done to further explore this clinical sign?
A) Liver function test B) CBC C) Platelet count D) Electrolytes
The nurse assessing that the patient with hepatic encephalopathy who has a flapping tremor of the hands will document this condition in the patient's chart as:
A) Asterixis B) Constructional apraxia C) Fetor hepaticus D) Palmar erythema
Which physical assessment technique would be used to determine the AP:lateral ratio?
1) Inspection 2) Palpation 3) Percussion 4) Auscultation
To assess a neonate's pain level, the nurse:
a. Observes for presence of tachycardia, hypertension, pallor, and perspiration. b. Recognizes that neonates have neurologically undeveloped pain-related responses. c. Expects a neonate in pain to have manifestations of depression and withdrawal. d. Assesses the neonate for sleep disturbance and irritability.