Which of the following high-risk neonates would the nurse plan for prior to delivery?
1. The infant born by cesarean section who develops respiratory distress
2. The neonate born to a diabetic mother
3. The neonate born to a mother with four other natural children
4. The neonate born to a mother whose last baby had a congenital anomaly
2
Rationale: The infant born to a diabetic mother will require close monitoring of blood glucose levels, and is at increased risk for complications, so this infant will be considered high-risk even before birth. The other infants will not be considered high-risk until problems develop.
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An adult patient who has undergone an implantable cardioverter defibrillator (ICD) procedure asks about the purpose of this device. The nurse's best response would be:
A) "To detect and treat ventricular fibrillation and ventricular tachycardia" B) "To detect and treat bradycardia" C) "To detect and treat atrial fibrillation" D) "To shock your heart if you have a heart attack at home"
A patient's vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg
Twenty minutes after the transfusion was begun, the patient began complaining of feeling "itchy and hot." The nurse discovered a rash on the patient's trunk. Vital signs were T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention? a. Administer an antihistamine (antiallergenic) medication. b. Flush the blood tubing with D5W immediately. c. Prepare for emergency resuscitation. d. Stop the blood transfusion immediately.
A couple who have a 7-year-old son have been experiencing growing tension and anxiety in their relationship. However, the tension and anxiety between them lessened when the mother began focusing most of her attention on the son
When applying the family systems therapy model concept of triangulation, which of the following would the nurse expect to assess in the child? A) Enjoying his mother's increasing attention and growing even closer to her B) Growing distant from his father and blaming him for all of the family's problems C) Developing problematic symptoms in response to his mother's increasing attention D) Resenting mother for her suffocating attention and his father's growing distance
Ellie, a 9-year-old girl, was adopted by a family at the age of 4 after several years of severe neglect by her birth family
The adoptive family has been reporting that Ellie is angry a lot, manipulative with her teachers, and does not seek positive attention. The nurse working with Ellie will need to: 1. Provide education on decreasing stimuli in the home environment that triggers the anger. 2. Realize Ellie may have attachment issues related to her previous history and will need to encourage the family to be active in her care. 3. Support the family in the decision-making process of continuing to let Ellie live in the home. 4. Discuss inpatient therapy to decrease Ellie's manipulative behavior patterns.