Which statement is typical of data collected from a patient with an anterior cruciate ligament (ACL) tear?
A) "I heard my knee pop, and then it gave out."
B) "My knee has locked up."
C) "My knee is weak and buckles."
D) "My knee doesn't move smoothly."
A) "I heard my knee pop, and then it gave out."
Explanation: A) At the time of an ACL injury, the patient typically reports intense pain and a feeling that the knee "popped" and "gave out."
B) With a meniscus tear, the patient reports feeling that knee is "locking up" or not moving smoothly, and a feeling that the knee is weak or "buckling."
C) With a meniscus tear, the patient reports feeling that knee is "locking up" or not moving smoothly, and a feeling that the knee is weak or "buckling."
D) With a meniscus tear, the patient reports feeling that knee is "locking up" or not moving smoothly, and a feeling that the knee is weak or "buckling."
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An infant of African origin is being cared for by parents who immigrated to the United States 6 months prior. The mother is using an herbal paste to treat the baby's diaper rash. What should the nurse do to ensure cultural competence?
1. Instruct the mother to stop using the paste. 2. Ask the mother to explain the ingredients in the paste. 3. Provide the mother with another cream to use for the diaper rash. 4. Explain to the mother that herbal ingredients are harmful to the baby.
The nurse asks the mother of a child with a chronic illness many questions as part of the assessment. The mother answers several questions, then stops and says, "I don't know why you ask me all this. Who gets to know this information?"
The nurse should respond in what manner? a. Determine why the mother is so suspicious. b. Determine what the mother does not want to tell. c. Explain who will have access to the information. d. Explain that everything is confidential and that no one else will know what is said.
The client is being treated with Bactrim. The nurse should anticipate seeing an increase in the client's serum:
a. glucose. b. potassium. c. BUN and creatinine. d. calcium.
Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup?
a. Testing for Ortolani sign b. Assessment for stereognosis c. Blood pressure measurement d. Assessment for the presence of the startle reflex