You remove his sock and find a large hematoma forming on the lateral aspect of an already
swollen ankle. The ankle also shows the color of a bruise that is several days old. You inquire
about D.M.'s pain perception.
He states, "It doesn't feel too bad now, but I sure saw stars
when it popped." What is the significance of his statement?
What will be an ideal response?
• His ankle is probably fractured, or he has snapped or torn a ligament.
• He has probably ingested a significant quantity of beer, enough to dull his sensory perception.
• An x-ray examination should be performed.
• Plans should be made to admit him to the hospital for detoxification management, as well as care
of the ankle.
• Contact the case manager and social worker.
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The nurse is completing an admission assessment. The assessment form allows for the separation of subjective and objective data. Which data is considered subjective?
Select all that apply. 1. The client's mother informs the nurse that her daughter has not been sleeping due to pain. 2. The client states, "I have pain in my belly that is 7 out of 10." 3. Abdominal assessment reveals a firm, hard abdomen. 4. The client is weak and looks very pale. 5. The client appears nervous during the data collection period.
Thrombolytic agents act to:
1. prevent clot formation. 2. lyse existing clots. 3. increase the blood's viscosity. 4. thin the blood.
What diluent is recommended?
What will be an ideal response?
In regard to intimate or sexual relationships with present or former clients, the ANA Standards of Psychiatric-Mental Health Clinical Nursing Practice:
a. discourage these intimate or sexual relationships b. have nothing written on this subject, leaving it to the state boards of nursing c. forbid such interactions with present or former clients d. recommend a waiting period of 5 years after caring for a client