A nurse is examining a 2-year-old child at the healthcare facility diagnosed with ataxic
cerebral palsy. The child is unable to perform fine leg movements and has a wide-based
gait.
What other distinguishing features should the nurse look for in this client?
A) Problems with depth perception
B) Writhing involuntary movements
C) Evidence of full or partial paralysis
D) Increased muscle tone or spasticity
A
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Anemia is a common but not normal finding in the elderly client. Anemia will affect the older client in which way?
A) increasing the oxygen-carrying capacity of the blood B) increasing skin pallor and dyspnea on exertion C) decreasing pulse and respiratory rate D) increasing tissue oxygenation
The nurse is gathering information from the family of a patient who is experiencing confusion. An important question the nurse should ask the family is:
1. "Are you sure she is confused? Maybe she just didn't hear what you were say-ing." 2. "When did you first think she might be confused and tell me exactly what hap-pened." 3. "Did something bad happen to her during her childhood?" 4. "How can you say she is confused? She knows who she is."
Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as indicating which of the following?
A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled
A patient will begin taking propranolol (Inderal) for hypertension. Which statement by the nurse is important when teaching this patient about the medication?
a. "Check your hands and feet for swelling and report that to your provider." b. "It is safe to take this medication with a calcium channel blocker." c. "Stop taking the drug if you become short of breath." d. "Take your pulse and do not take the medication if your heart rate is fast."