While assessing a 10-month-old infant, the nurse notices that the sclerae have a yellowish tint. Which organ system would require more in-depth assessment based on this finding?
1. Hepatic
2. Cardiac
3. Genitourinary
4. Respiratory
1
Explanation:
1. This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver or hepatic system.
2. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.
3. Tenting of the skin and dry mucous membranes could be signs of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.
4. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.
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The nurse has identified lack of normalcy in a family with a child who has a mild but discernible genetic defect. Which nursing interventions should the nurse plan?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Advocating for the client's insurance to pay for additional services 2. Educating the teachers at the child's school about the disorder and treatments 3. Helping to coordinate care among the three clinics the child goes to each month 4. Alerting the family against involving the child in activities in which failure is possible 5. Encouraging the family to avoid public gatherings
A patient comes into the emergency department with severe burns over the face, arms, legs, and back after spending the day boating with friends. The skin is dry and very red with brisk capillary refill. How would the nurse classify this patient's burn injuries?
1. Superficial 2. Deep partial thickness 3. Superficial partial thickness 4. Full thickness
The nurse should assess a patient with a long leg cast for which signs that would indicate compromised circulation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Swelling of the toes 2. Drainage on the cast 3. Elevated temperature 4. Foul odor 5. A tight cast
Mr. and Mrs. Close are a happily married couple in their 70s who have been together for 50 years. They present together at your clinic and seem reluctant to state their concern
In response to your observation about their uneasiness, Mr. Close tells you that they have been having difficulties with intercourse and don't know who to talk to. "Our children think it is shameful that we still have sex at our ages, so we can't talk to them." You respond: A) "I think your children have your best interest at heart." B) "What do you think about people your age being sexual?" C) "It is perfectly normal to be intimate at any age. Here are some pamphlets about sexuality in later adult years." D) "I wish more people thought as you do about sexuality!"