Which of the following would the nurse include in the rationale for the nursing intervention to maintain body alignment? Select all that apply
A) Maintaining body alignment prevents contractures
B) Maintaining body alignment promotes circulation
C) Maintaining body alignment assists in urinary elimination
D) Maintaining body alignment decreases pain
E) Maintaining body alignment decreases respiratory effort
A, D
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Maintaining body alignment prevents contractures and decreases pain from misalignment of the musculoskeletal system. In some cases, maintaining alignment may promote circulation, assist in urinary elimination, and decrease respiratory effort but not routinely to include in the general rationale.
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A child is admitted for scald burns to his buttocks and thighs. According to the mother, she was preparing the child's bath and before she could test the water, the child fell in and was scalded. The nurse would suspect child abuse because:
1. The burns are uneven, with some burns deeper than others. 2. The child's hands and feet are free of burns. 3. In addition to the main burn site, there are splash burns surrounding the area. 4. The mother was home alone with the child.
A patient in the supine position with the head flexed to the chest is not experiencing any pain, resistance, or flexion of the hips or knees. What is the nurse assessing in this patient?
1. doll's-eyes reflex 2. Brudzinski sign 3. Babinski reflex 4. Kernig sign
A nurse is teaching a class on hypertension at the local Chamber of Commerce meeting. What risk factor would the nurse be sure to address to the class?
A) Quitting cigarette smoking 5 years ago B) Loss of 50 pounds within the last 12 months C) High cholesterol and low triglyceride levels D) Family history
A pediatric nurse who is employed in a busy ambulatory clinic setting is informed by the nurse manager that average nursing time allocated for each child and family is being reduced to 10 minutes to more efficiently manage the clinic
The nursing activities must include a nursing assessment and discussion on anticipatory guidance. Which of these strategies should the nurse utilize in the plan of care delivery? 1. Attempt to complete the assessmentand education in 10 minutes but extend the time whenever the nurse deems necessary. 2. Plan to do the anticipatory guidancefirst since either the nurse practitioner or the physician can perform the assessment of the child. 3. Ask each parent to complain to thenurse manager that there is not adequate time to talk with the nurse at each visit. 4. Focus anticipatory guidancestrategies on topics that the parent or child have expressed as an area of interest.