During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a nursing diagnosis plan
What does this data represent?
a.
Symptoms
b.
Data clustering
c.
Signs of fluid overload
d.
Urinary retention
ANS: B
The nurse organizes data, and those that are related are referred to as clustering.
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The newborn delivered at term is being discharged. The parents are asking the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if the parent states:
1. "A quick cool bath will help wake up my son for feedings." 2. "I can check my son's temperature under his arm." 3. "My baby should be dressed warmly, with a hat." 4. "Cuddling my son will help to keep him warm."
A patient who is also a nurse is being treated for anxiety with a selective serotonin reuptake inhibitor. She asks about the rationale for use of this agent rather than a benzodiazepine. Which of the following is the nurse's best response?
a. "Selective serotonin reuptake inhibitors are better for the control of bodily symp-toms than benzodiazepines." b. "Selective serotonin reuptake inhibitors provide a more rapid and durable re-sponse to the uncomfortable anxiety symptoms." c. "Benzodiazepines currently have no role in the treatment of anxiety." d. "Selective serotonin reuptake inhibitors are better for reducing the cognitive and psychic symptoms of anxiety than benzodiazepines."
A patient experienced a mild infusion reaction when amphotericin B was administered yesterday. What can the nurse do to decrease the next day's infusion reaction?
a. Administer meperidine 4 hours before the infusion. b. Pretreat the patient with acetaminophen. c. Administer dexamethasone simultaneously with the drug. d. Administer diphenhydramine after the infusion.
The nurse is teaching a class on breastfeeding to expectant parents. Which is a contraindication for breastfeeding?
a. Mastitis b. Twin births c. Inverted nipples d. Maternal cancer therapy