When the nurse is caring for a postpartum client, assessment would be focused on which priority areas? (Select all that apply.)
a. cervical enlargement d. depression
b. episiotomy or incision e. lochia
c. bladder distention f. breasts
B, C, E, F
BUBBLE = breasts, uterus, bowels, bladder, lochia, episiotomy (laceration or c-section incision)
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The nurse will most likely assess which of the following clinical manifestations in a client who was diagnosed with Creutzfeldt-Jakob disease?
A) Change in behavior and memory and loss of coordination leading to encephalopathy B) Gastrointestinal problems like vomiting and diarrhea C) Muscle inflammation and edema, making movements very painful D) Projectile vomiting, hypertension, and drowsiness caused by elevated ICP
A nurse sees a patient get struck by lightning during a thunderstorm on a golf course. What is the first action the nurse should perform?
1. Check breathing and circulation. 2. Look for entrance and exit wounds. 3. Cover the victim to prevent heat loss. 4. Move the victim indoors to a dry place.
The home care nurse is teaching the client with hepatitis A and her family members how to prevent transmission of the disease from the infected client to noninfected family members
Which action is most important to teach about how to prevent uninfected family members from becoming infected? A. Ensuring that all family members wash their hands before eating B. Preventing the client from preparing food for herself or the rest of the family C. Washing the client's dishes separately from those of the rest of the family D. Having the infected client wear a mask over the nose and mouth when interacting with all family members
A woman with an artificial mitral valve develops heart failure at the 20th week of pregnancy. Which of the following measures would you stress with her during the remainder of the pregnancy?
A) Obtaining enough rest B) Maintaining a high fluid intake C) Beginning a low-impact aerobics program D) Discontinuing her prepregnancy anticoagulant