Your patient is suffering from herpes zoster along the trigeminal nerve distribution of the face. You should carefully assess for the presence of:
A. Keratitis
B. Uveitis
C. Scleritis
D. Conjunctivitis
ANS: A
Keratitis is inflammation of the cornea that can lead to blindness in the affected eye. Keratitis is commonly caused by herpetic and other infections, ischemia, chemical exposures, foreign bodies, or corneal abrasions. Keratitis is noteworthy because it can lead to ulcerations, opacities, and blindness of the affected eye; thus, patients suspected of this disorder should be immediately referred to an ophthalmologist.
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The nurse has to insert a nasogastric tube for the purpose of temporary tube feedings. To determine the length of the tube, the nurse should use which measurement?
a. Tip of the nose to the xiphoid process of the sternum and add an additional 20 cm b. Tip of the chin to the earlobe to xiphoid process of the sternum c. Tip of nose to the earlobe to xiphoid process of the sternum d. Tip of the earlobe to the nose to the umbilicus
A patient who has attempted suicide by taking a handful of ibuprofen (Motrin) is admitted to the mental health unit
She had attempted suicide three times previously, each by overdose on over-the-counter medications, and in each case was found by family or peers in time to prevent her death, eventually being admitted to this mental health unit each time. Which of the following nursing responses would be most appropriate? a. Search her and her belongings for pills and other dangerous objects, then minimize the attention given to her by staff in order to reduce secondary gains. b. When medically stable, confront her with her pattern of maladaptive coping, noting that the low lethality of her attempts suggests she is seeking attention. c. Discuss with her family ways that they can reduce her attention-seeking suicide gestures by keeping all medications locked and not responding to histrionic behavior. d. Place her on one-to-one observation because her history of previous attempts suggests she is at high risk of suicide; once medically stable, begin intensive psychiatric treatment.
In assessing the client who had a radical nephrectomy for a renal cell carcinoma 6 hours ago, a nurse notes that the client's blood pressure has decreased from 134/90 to 100/56 and the urine output is 20 mL for this past hour
What is the nurse's best first action? A. Position the client so that the remaining kidney is not dependent. B. Measure the specific gravity of the urine. C. Document the findings as the only action. D. Notify the physician.
A patient is being discharged home. Which information should the nurse include?
a. Acuity level b. Community resources c. Standardized care plan d. Kardex