A nurse is seeing a baby with a diagnosed cleft lip. What assessment finding indicates to the nurse that a priority outcome has been met?
A.
Absence of infection
B.
Appropriate weight gain
C.
Interacts at developmental age
D.
Normal cranial nerve function
ANS: B
Maintaining adequate nutrition is a priority concern in a child with cleft lip or palate, because these defects interfere with feeding. An appropriate weight gain signifies that feeding is adequate. Infection would be a concern in a recent defect repair. Interacting appropriately and having normal cranial nerve function are not specifically related to this defect.
You might also like to view...
Substance abuse in adolescents can be a result of:
1. peer pressure and knowing who is dealing drugs. 2. family dysfunction and another family member who is using drugs. 3. wanting to feel part of their group and family dysfunction. 4. ineffective communication and denial.
Depending on the institution and surgeon, a patient will have between two and four chest tubes. The nurse documents chest tube output hourly
What should the nurse do if there is an increase in output of greater than 100 milliliters in 1 hour? Select all that apply. 1. Report to the surgeon. 2. Check the hemoglobin and hematocrit. 3. Administer a blood transfusion. 4. Notify the family. 5. Nothing, as this is normal.
The nurse manager observes a new graduate nurse complete assessment activities for a newly admitted client. Which actions indicate that the graduate needs assistance with the assessment process?
1. Reviews client record 2. Establishes a database 3. Performs nursing actions 4. Reviews nursing literature 5. Determines client's strengths, risks, and problems
The common element seen in every type of bereavement is:
a. Bereavement is a predictable process that is a result of loss. b. The individual has experienced the loss of something of importance. c. Acute depression is generally experienced by all who grieve for a loss. d. The course of the grieving will be determined by the seriousness of the loss.