After completing the physical examination of a patient in the seated and lying positions, the nurse asks the patient to stand. What body areas will the nurse assess with the client in this position?
A) Cervical spine
B) Thorax
C) Axillary nodes
D) Gait and balance
D
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The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? The student nurse:
1. Listens to bowel sounds then assesses the head for skull consistency, and size and tension of fontanels. 2. Checks for Ortolani's sign, then palpates femoral pulse, then assesses respiratory rate. 3. Determines skin color, then describes shape of the chest and looks at structures and flexion of the feet. 4. Counts the number of cord vessels, then assess genitals, then sclera color and eyelids.
A nurse comes to a mandatory education session wearing a shirt with a picture and slogan that is degrading to nursing. What should the manager do first?
1. Tell the employee to go home and change. 2. Check the human resources policies regarding appropriate dress. 3. Ask the employee why the shirt was worn to this event. 4. Bring the employee a scrub shirt from surgery to change into.
The nurse develops a care plan for a patient who has been prescribed a folic acid derivative that includes what priority nursing diagnosis?
A) Deficient knowledge regarding drug therapy B) Monitor possibility of hypersensitivity reactions C) Acute pain related to injection or nasal irritation D) Risk for fluid volume imbalance related to cardiovascular effects
When a clean-voided specimen is ordered, the nurse should instruct the client to:
a. clean the area as directed and collect the initial urine voided. b. clean the area as directed, start to void into the toilet, and collect the urine in the sterile cup after a good flow of urine has been established. c. clean the area as directed and collect all the urine voided. d. clean the area as directed, start to void, and collect three samples at different times during the voiding.