The monitor tracing indicates decelerations, rounded in shape, beginning with the onset of the contractions, and ending as the contractions end. The appropriate nursing action is to
a. increase the IV rate
b. turn the client to the left lateral position
c. prepare for an emergency cesarean section
d. reassure the client that the fetus is responding normally to head compression
D
Variable decelerations are normal in labor, and are caused by cord compression from the contraction. Increasing the IV rate and preparing for emergency cesarean section are not necessary for variable decelerations. Turning the client to the left lateral position is not necessary for variable decelerations, unless the mother would be more comfortable in the left lateral position.
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Two hours after admission for asthma exacerbation, the 10-year-old boy is lethargic with mottled skin color. He has increased the use of accessory muscles and demonstrates nasal flaring
He is unable to speak and his respiratory rate has increased. The nurse would suspect: 1. Improvement in his condition is imminent. 2. Respiratory failure is imminent. 3. The medical diagnosis is incorrect and the child should be diagnosed with pneumonia. 4. The child may be receiving too much oxygen, which is a respiratory depressant.
A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the "AIDS guy" and wondering how the client contracted the disease
What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the unit's nursing management. d. Tell the client that other staff members are talking about him or her.
The nurse tells the schizophrenic patient "it's time to go to bed." The patient responds with "it's time for bed, it's time for bed, it's time for bed." The patient's response is an example of ____________________
ANS:
Select the best response for the nurse who receives a query from another mental health professional seeking to understand the difference between a DSM-IV-TR diagnosis and a nursing diagnosis
a. "There is no functional difference between the two. Both identify human disorders." b. "The DSM-IV-TR diagnosis disregards culture, whereas the nursing diagnosis takes culture into account." c. "The DSM-IV-TR diagnosis is associated with present distress or disability, whereas a nursing diagnosis considers past and present responses to actual mental health problems." d. "The DSM-IV-TR diagnosis affects the choice of medical treatment, whereas the nursing diagnosis offers a framework for identifying interventions for phenomena a patient is experiencing."