The nurse is assessing a client. Which data are considered data from a primary source?
a. The client's spouse tells the nurse the client seems upset.
b. The client reports right lower quadrant pain.
c. The physician describes the client as being overanxious.
d. The lab report shows an elevated white cell count.
ANS: B
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A client had a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?
a. Urine output of 20 mL/hr b. Systolic blood pressure increase of 10 mm Hg c. Respiratory rate drop from 18 to 14 d. A 3-pound drop in weight
A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure at school that lasts more than 5 minutes. Breathing is not impaired. Some postictal confusion occurs
What is the most appropriate initial action by the school nurse? a. Stay with child and have someone else call emergency medical services (EMS). b. Notify the parent and regular practitioner. c. Notify the parent that the child should go home. d. Stay with the child, offering calm reassurance.
A nurse assesses a 3-year-old child diagnosed with autistic disorder. Which finding is most associated with the child's disorder?
a. Toilet training complete b. Inability to identify colors c. Failure to develop interpersonal skills d. Anxiety when separated from a parent
Nurses are accountable for participating in the development of legislation and family policy. The Family Leave legislation passed in 1993:
1. Allows a person to resign from his job and retain his health insurance 2. Prevents nurses from discussing family information with colleagues 3. Gives Medicaid to families that cannot afford health insurance 4. Allows a family member to take a defined about of tine off for family events