An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration?
A) Elbows
B) Lips
C) Nail beds
D) Sclerae
Ans: D
Feedback:
Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes.
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1. polyuria. 2. weight gain. 3. muscle weakness. 4. mild nausea.
An 80-year-old patient is brought to the urgent care center. The patient is unconscious and the physician suspects a cerebrovascular accident (CVA/stroke). You are assisting, so your first priority for this patient is to:
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The nurse is caring for a client in the neurological intensive care unit (ICU) with head trauma. The client is being monitored for increased intracranial pressure (IICP)
Using the Monroe-Kellie hypothesis as a basis for explanation, which comment by the nurse to the client's family would be most appropriate? A) "There is nothing that can be done." B) "Increasing brain pressure decreases the amount of blood flow to the brain itself." C) "The pressure in the brain is increasing because the brain is shrinking." D) "Because there is more pressure in the brain, the blood flow is also increasing."
A Chinese woman who is 12 weeks pregnant reports to the nurse that ginseng and bamboo leaves help reduce her anxiety. How should the nurse respond to this patient?
1. Advise the patient to give up the bamboo leaves but to continue taking ginseng. 2. Advise the patient to give up all herbal remedies during the first trimester except for ginger. 3. Tell the patient that her remedies have no scientific foundation. 4. Assess where the patient obtains her remedy, and investigate the source.