What should the unlicensed assistive personnel report to the nurse when caring for a client's ears?
1. Excessive earwax
2. Loud talking
3. Presence of a hearing aid
4. Presence of any drainage
Correct Answer: 4
Rationale 1: Excess earwax is not an immediate problem.
Rationale 2: Loud talking could be an indication the client is hard of hearing, which is not an immediate threat.
Rationale 3: The presence of a hearing aid should already be noted on the client's admission assessment.
Rationale 4: The health care provider should report any drainage from the ears to the nurse.
You might also like to view...
To assist with a gastric lavage of an obtund patient who has ingested a known poison, the nurse must:
A) Place the patient in a semi-Fowler's position. B) Discard aspirate into the toilet. C) Instill the antidote before aspirating stomach contents. D) Inspect the oral cavity for loose teeth.
A nurse is providing education to a group of college students about the long-term effects of alcohol. Which statement by a student indicates understanding of the teaching?
a. "Chronic alcohol use contributes to the development of osteoporosis." b. "Chronic use of alcohol can actually de-crease the risk of cardiomyopathy." c. "Even small amounts of alcohol are related to the development of certain cancers." d. "Pancreatitis is not a common problem among chronic users of alcohol."
A patient who received the thrombolytic drug alteplace (Activase) asks the nurse why continuous heparin is now infusing intravenously. What is the nurse's best response?
a. "There may be additional clots in your body and we want to be sure they are all dissolved." b. "Once the clot is dissolved, heparin is given continuously to prevent any new clots from forming." c. "The heparin finishes the job of dissolving the clot that the alteplace started." d. "Heparin is infused continuously in case we need to give additional dosages of alteplase."
The nurse is reviewing a care plan for an assigned client diagnosed with paranoid schizophrenia. Which of the following would be a priority diagnosis for this client?
A) Risk for self-directed violence B) Altered nutrition, less than body requirements C) Defensive coping D) Altered family processes