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A dark skinned adult is in the emergency department following a car crash, resulting in serious injuries and severe bleeding. The nurse notes that the patient’s skin color is ashen, gray.  How should the nurse respond?

The nurse is assessing the abdomen of an adult patient with a history of liver cirrhosis.  Assessment reveals an abdomen that is protuberant and firm with tight, shiny skin and bulging flanks.  What is the etiology of these assessment findings?

The nurse is assessing a patient’s pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? (Select all that apply.)

A patient says that she has recently noticed a lump in the front of her neck below her “Adam’s apple” that seems to be getting bigger.  During the assessment, what finding would lead the nurse to suspect that this may not be a cancerous thyroid nodule?

What is the priority nursing action for a patient who reports having a “cold” and the nurse notes enlarged, firm and tender submandibular lymph nodes?

A 68-year-old woman is in the eye clinic for a checkup.  She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren.  On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal.  What do these finding suggest?

How will the nurse document assessment of the eyes in an adult patient that has drooping of the left eye lid with a smaller distance between the upper and lower lids on the left?

Picture1.png What type of pressure injury is this?

Match each patient with the appropriate pain scale that the nurse will use to perform a pain assessment.

Picture1.png What type of pressure injury is this?