The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which of the following data collected by the nurse are presumptive signs of her pregnancy? Select all that apply
A) Breast changes
B) Ultrasound pictures
C) Fetal heartbeat
D) Amenorrhea
E) Hydatidiform mole
F) Morning sickness
A, D, F
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Presumptive signs are possible signs of pregnancy that appear in the first trimester, often only noted subjectively by the mother (e.g., breast changes, amenorrhea, morning sickness). Probable signs are signs that appear in the first and early second trimesters, seen via objective criteria, but can also be indicators of other conditions (e.g., hydatidiform mole). Positive signs affirm that proof exists that there is a developing fetus in any trimester and are objective criteria seen by a trained observer or diagnostic study, (e.g., ultrasound.)
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Which of the following statements is true regarding a nurse's job description?
a. As long as the nurse follows the American Nurses Association Standards of Care, the job description is irrelevant in a negligence allegation. b. Job descriptions must be reflective of the accepted standard of care. c. Institution-specific job descriptions are not legally acceptable. d. Job descriptions should be vague in describing nursing functions to avoid claims of negligence.
The pediatric nurse researching the incidence of autism spectrum disorders knows that:
Select all answers that apply. A) 1 out of 10 children are diagnosed with this developmental disorder and/or behavioral problem. B) the reported number of children with autism spectrum disorders has decreased since the early 1990s. C) the Centers for Disease Control and Prevention (CDC) estimates that 1 in 166 children receive a diagnosis of an autism spectrum disorder. D) in 1991, the U.S. Department of Education added autism as a category for special education.
Which of the following would most likely be a problem for the nurse making home visits? (Select all that apply.)
a. Assessing the client may be more complex when family and environmental factors are considered in the assessment. b. The nurse may be unable to care for as many clients because of the time lost in transportation. c. Clients will be unable to receive individualized care. d. Teaching may be more time-consuming when both the client and the family are involved. e. The nurse may sometimes be concerned for personal safety. f. It may be difficult to control distractions, such as noisy children.
A schizophrenic client says to the nurse, "I keep getting these thoughts and hearing voices. They worry and consume me so that I can't always stop myself like my health care provider told me to." Which intervention would the nurse suggest as a distraction technique?
A. "Pretend that you're on the phone and talk to the voices." B. "Have you tried to count back from 100 or listen to music?" C. "The next time this happens, try telling the voices to go away." D. "Tell the voices that you will only listen to them just before you watch television at 8:30 in the evening."