The nurse reviews nursing implementations that can help relieve the stressors of hospitalization for a child to include: (Select all that apply.)
a. Providing a consistent caregiver
b. Keeping explanations to a minimum
c. Encouraging parents to stay with the child
d. Discouraging play in order to keep the child calm
e. Allowing the child to make as many choices as possible
A, C, E
Consistent caregivers, presence of the parent(s), and allowing as many choices as possible will relieve the stress of hospitalization. Explanations should be frequent and age-appropriate, and play should be encouraged.
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The nurse measures the client's blood pressure, and the client inquires what the reading was. The nurse does which of the following?
1. Calls the physician to ask if the blood pressure can be shared with the client. 2. Tell the client that the doctor will be with him shortly to discuss his BP. 3. Tell the client that the blood pressure reading must be interpreted by the physician. 4. Tell the client what the reading was and its meaning, using it as a teaching opportunity.
The nurse is caring for a patient diagnosed with pneumonia. The patient has a BP 160/94, P 102, R 28, crackles in posterior lower lobes bilaterally, oxygen saturation 89%, and complains of shortness of breath upon exertion
The highest priority nursing diagnosis for this patient is: a. Activity intolerance b. Impaired gas exchange c. Ineffective cardiopulmonary tissue perfu-sion d. Self-care deficit: Bathing and hygiene
The nurse is caring for a client after a Whipple procedure. Which manifestations might indicate that a complication from the operation has occurred? (Select all that apply.)
a. Urinary retention b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr
A tearful patient at the mental health center says, "I should be dead." What is the most important first task for the nurse in assessing this patient?
a. Ascertain the lethality of the suicide plan. b. Establish a rapport with the patient. c. Determine the risk factors for suicide. d. Encourage expression of feelings.