A 6-year-old boy is admitted to the hospital for a surgical procedure associated with a hospital stay
When the nurse asks his mother about the boy's sleep patterns, she says, "Sometimes he will get out of bed, walk into the kitchen, and get the cereal out of the cabinet. Then he just turns around and goes back to bed." The nurse explains that he is sleepwalking. The best nursing diagnosis for Tad would be:
a. Risk for Insomnia related to sleepwalking.
b. Risk for Fatigue related to sleepwalking.
c. Disturbed Sleep Pattern related to dyssomnia.
d. Risk for Injury related to sleepwalking.
D
Sleepwalking occurs during stages III and IV of NREM sleep. The sleeper leaves the bed and walks about with little awareness of surroundings. He may perform what appear to be conscious motor activities but does not wake up and has no memory of the event on awakening. The boy is at high risk for injury when sleepwalking because of his lack of awareness of his surroundings. Insomnia is a medical diagnosis rather than a nursing diagnosis. Certainly his sleep pattern is disturbed; however, there is little in the way of independent actions that the nurse could take for either the problem or etiology of this diagnosis, so it would not be useful. The boy does not awaken while sleepwalking and is not likely to experience fatigue from the event.
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A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule
is that the lump (nodule): a. Is tender. b. Is mobile and not hard. c. Disappears when the patient smiles. d. Is hard and fixed to the surrounding structures.
Which statements would the nurse educator evaluate as indicating a student's need for additional instruction on trisomic rescue?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. "Trisomic rescue occurs when the extra chromosome is isolated and lost." 2. "The effect of trisomic rescue depends on when it occurs." 3. "In somatic cells it is best for trisomic rescue to take place later rather than earlier." 4. "In sex cells it is best for trisomic rescue to take place sooner rather than later." 5. "Trisomic rescue can be induced through ionizing radiation."
A nurse is preparing a patient for suturing and provides patient teaching regarding the use of the local anesthetic. The nurse asks the graduate nurse assisting her questions about the anesthesia to evaluate the graduate nurse's understanding
Which statement best demonstrates the graduate nurse's accurate understanding of the effects of local anesthesia? a. Perception of heat and cold are not affected by local anesthetics. b. Local anesthetics block the sensation of deep pressure first. c. It takes longer for local anesthetics to block small, nonmyelinated neurons. d. Local anesthetics block conduction in motor nerves as well as sensory nerves.
The nurse caring for an immunosuppressed 3-year-old is teaching the mother about proper oral hygiene. Which of the following responses from the mother indicates a need for further teaching?
A) "I need to carefully check for skin breakdown." B) "I must really scrub her teeth and gums well." C) "I must use a soft toothbrush." D) "I can use a soft gauze sponge to care for her gums."