What are your priorities for this patient?
What will be an ideal response?
• M.B.'s symptoms are probably the result of a distended bladder and urinary retention. First, obtain
a bedside bladder ultrasound scan to get an estimate of the number of milliliters being retained in
the bladder. Then you would expect an order to insert an indwelling catheter. Draining the bladder
should alleviate his symptoms. Although rare, bladder rupture can occur, so placement of the
catheter must be completed ASAP.
• Help reduce M.B.'s anxiety by keeping him informed about what is happening and updating him
on his treatment plan.
• Be aware that if the urinary retention is being caused by an enlarged prostate gland, the attempt
to advance an indwelling urinary catheter might be difficult and uncomfortable for the patient.
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The mother of a hospitalized toddler states, "He cries when I visit. Maybe I should just stay away." What is the nurse's best response?
a. "Perhaps you are right. He only gets upset when you have to leave." b. "It is important that you are here. This is a common reaction in children when they are separated from their parents." c. "It might be easier for your child if you would stay with him, but this decision is up to you." d. "We take good care of him and he seems fine when you are not here."
The nurse is caring for a patient newly diagnosed with a primary brain tumor. The patient asks the nurse where his tumor came from. What would be the nurse's best response?
A) "Your tumor originated from somewhere outside the central nervous system." B) "Your tumor is pituitary in origin." C) "Your tumor originated from cells and structures within the brain." D) "Your tumor is from nerve tissue somewhere in your body."
What action should the nurse take before administering a drug in suspension form?
a. Administer the drug in its separated form. b. Prepare the intravenous line for administration of the drug. c. Document the administration time. d. Shake the suspension thoroughly.
The nurse is assessing a child during a well-baby checkup. The parents express concern that their baby does not act as other babies of their friends
The nurse suspects the child may have cerebral palsy when the parents state which of the following? 1. "My 6-month-old baby is rolling from back to prone now.". 2. "My 3-month-old fails to smile at me.". 3. "My 8-month-old can sit without support.". 4. "My 10-month-old is not walking.".