The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert but has dry mucous membranes
Which additional assessment data indicates to the nurse that the infant is experiencing an early to moderate stage of dehydration? 1. Bradycardia
2. Tachycardia
3. Increased blood pressure
4. Normal fontanels
2
Explanation:
1. Bradycardia is not a sign of dehydration.
2. Tachycardia is a sign that indicates moderate dehydration.
3. In dehydration, the blood pressure is hypotensive.
4. Fontanels would be sunken in moderate dehydration.
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A diabetic client is having difficulty with blood glucose control even though the client claims to be following a strict diet, exercise, and medication regime
Which of the following conditions would the nurse suspect to be the most likely cause of poor control? A) Hypertension B) Retinopathy C) Peripheral vascular disease D) Emphysema
A nurse warns a newly-admitted diabetic client that to avoid injury related to a common diabetic complication, the client should
a. always call for help before getting up. b. keep needed items within easy reach. c. only ambulate with assistance. d. wear house shoes while out of bed.
Which of the following statements, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?
A) "I can have a hamburger and French fries as soon as I wake up." B) "The better I eat before surgery, the more likely I will heal." C) "I might be sick to my stomach and throw up after surgery." D) "When I can eat again, the best meal would be steak and orange juice."
A patient tells the nurse, "I'm having a lot of pain in my hip." Which response(s) by the nurse most likely would stimulate the patient to provide the most complete data? Select all that apply
a. "Is your pain severe?" b. "Tell me about your pain." c. "When did you first notice this pain?" d. "How would you describe your pain?" e. "Is your pain better or worse than it was this morning?"