A newborn has a respiratory rate of 66 breaths per minute,
flaring nostrils, and is making a grunting sound during respiration. What health problem should the nurse consider based upon these findings?
A) The infant is burning brown fat
B) The infant is cold-stressed
C) The infant is in respiratory distress
D) The infant is experiencing radiation heat loss
Ans: C
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What intervention would make phototherapy most effective in reducing the indirect bili-rubin in an affected newborn?
a. Turn the infant every 2 hours. b. Increase oral intake of water between and before feedings. c. Place eye patches on the newborn. d. Wrap the infant in triple blankets to prevent cold stress.
When a distinction must be made as to whether a client is demonstrating confusion related to
depression or dementia, what nursing assessment would be of particular value? a. The client with dementia is pervasively angry and hostile. b. Early morning agitation and hyperactivity are present in dementia. c. The depressed client is preoccupied with leaving the facility to return home. d. Confusion seems to worsen at night when dementia is present.
A 4-year-old child is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an absence of pulse. What should the nurse do first?
a. Reposition the child and notify the practitioner. b. Notify the practitioner of the changes noted. c. Give the child medication to relieve the pain. d. Chart the observations and check the extremity again in 15 minutes.
The Myers-Briggs personality types are based on a psychological testing instrument which consists of four major pairs of categories of people. Which of the following is not one of these four pairs of categories?
a. knowing or growing b. introvert or extrovert c. sensing or intuitive d. thinking or feeling