During assessment of the reflexes in the newborn, the nurse notices that the newborn
baby turns her head in the direction of the touch when the cheek is stroked. What is this
reflex called?
A) Babinski's reflex
B) Moro's reflex
C) Stepping reflex
D) Rooting reflex
D
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A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)
a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.v
Pathogenic organisms come in a variety of different forms. Each infection must be carefully evaluated to determine the specific causative organism and the therapy that will be most effective against it. This is usually done through:
1. stool examination. 2. scraping of lesions. 3. incubation of discharge from lesions. 4. culture and sensitivity studies.
The nurse is assessing the way the patient walks. The manner of walking is known as the patient's
a. Activity tolerance. b. Body alignment. c. Range of motion. d. Gait.
The nurse is admitting a patient to the medical unit. Which of the following are reasons the nurse may perform a nutritional screening on this patient? (Select all that apply.)
a. To assess risk for malnutrition b. To assist with feeding c. To identify risk for aspiration d. To determine body weight