A nurse is assessing a client who was hit at the base of the skull with a blunt instrument causing a skull fracture. What assessment finding does this nurse anticipate during the inspection?
a. Tinnitus, vertigo, and dizziness
b. Clear drainage from the ear and nose
c. Loss of hearing and smell
d. Purulent drainage from the ear and bloody drainage from the nose
ANS: B
You might also like to view...
The nurse is attempting to get the patient to sign the operative consent. When asked if the health care provider explained the procedure to the patient, the patient replies "Not much." The nurse should:
a. develop a comprehensive teaching plan related to the surgical procedure. b. ask the patient what information the doctor has explained about the surgery. c. contact the surgeon and ask for further clarification of information given to patient. d. focus on postoperative exercises and home-care following surgery.
A patient who is prescribed niacin (Niacor) reports experiencing flushing and hot flashes. What is your best action?
a. Hold the drug and notify the prescriber. b. Give the niacin at least 1 hour before meals. c. Reassure the patient that this is an expected side effect. d. Administer the ordered NSAID 30 minutes before the niacin.
The nurse instructs the patient about postoperative coughing and deep-breathing exercises following abdominal surgery. Which technique should the nurse use to engage the patient in prevention of pneumonia and atelectasis?
a. Begin coughing and deep breathing when the patient is ready. b. Take a deep breath, hold it for 10 seconds, and exhale slowly. c. Support the incision when doing these ex-ercises. d. Begin coughing and deep breathing when the patient is wide awake.
A delusion represents a problem in which of the following areas?
A) Memory B) Motivation C) Orientation D) Thinking