When caring for a pregnant client with a heroin addiction, the nurse would monitor the client for which of the following?
A) Intrauterine growth restriction
B) Abruptio placentae
C) Respiratory complications
D) Hypoplastic philtrum
C
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A diabetic client is being screened for tuberculosis. The nurse administers the tuberculin skin test. Instructions related to the skin test should include:
1. The client must return within 24 to 36 hours to have the test assessed. 2. A positive reaction to the skin test is based upon redness around the injection site. 3. An induration area of 15 mm or greater is significant in this client. 4. An induration area of 10 mm or more is considered positive in this client.
Before performing the doll's eye or oculocephalic reflex, the nurse must verify
a. the absence of cervical injury. b. the depth and rate of respiration. c. a physician's order to perform the maneuver. d. the patient's ability to follow a verbal command.
A parent brings her baby in for a well-child checkup. Which action of the child should the nurse identify as an indicator of positive resolution of the central task of this age?
1. The child does not cry when the parent allows the nurse to hold the child. 2. The child shows mistrust when strangers approach. 3. The child becomes willful when disciplined. 4. The child does not play with other children.
When managing an angry and aggressive individual, which factor should a nurse address first?
A) Denial B) Trust C) Self-esteem D) Safety