A 17-year-old girl comes into the emergency department complaining of a memory gap of the previous night
She says she only had one drink but felt dizzy and disoriented. She woke up in a friend's bed but has no recollection of getting there. What action should the nurse take first?
A) Call Social Services to counsel her about blackouts related to alcohol abuse
B) Call Neurology so they can see her to rule out a neurologic impairment
C) Have the patient call her parents to get their permission to treat and counsel her
D) Complete a rape kit in case she has been abused while under the influence of Rohypnol
Ans: D
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The mother of a dying three-year-old child posts on Facebook: "Family and friends. Michael's heart is giving out. Looks like it will be tonight. He is surrounded by family and not in pain. I treasure every minute of being his mother
Pray for us." The nurse who has worked with the family recognizes that Michael's mother is in which stage of grieving according to Kubler-Ross? 1. Denial 2. Acceptance 3. Bargaining 4. Depression
You enter your patient's room and notice an ammonia odor. Which of the following conditions can cause an ammonia odor?
a. Renal failure c. Severe vaginitis b. Intestinal obstruction d. Diabetic ketoacidosis
The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a client favorite, will the nurse discourage?
A) A grilled chicken sandwich with mayonnaise B) A natural fruit salad with nuts C) A hot dog with catsup D) A fresh grilled tuna entrée with fresh asparagus
To assess the breast for discharge and protraction of the nipple, you would place
a. the fingertips of both hands on each side of the breast and press gently. b. one hand under the breast for support and gently press with the fingers of your other hand from the outer edge of the areola toward the nipple. c. your thumb and forefinger on the areola and press inward. d. your thumb and forefinger on the nipple and gently squeeze.