The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next?
A. Measure the infant's head-to-toe length.
B. Palpate the anterior fontanel for tension and bulging
C. Observe the infant for sunken eyes
D. Plot the measurement on the infant's growth chart.
Ans: B. Palpate the anterior fontanel for tension and bulging
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The nurse is explaining to a patient with dysrhythmia how the heart conducts impulses that cause myocardial cells to contract simultaneously. The patient asks what structure allows this conduction from cell to cell
Which structure should the nurse mention? A) Intercalated disks B) Nuclei C) Mitochondria D) Ribosomes
An older woman who receives intravenous (IV) fluids is making wide gesticulations with her arms and loudly insulting the nursing staff. Which intervention should the nurse implement to maintain safe, effective nursing care initially?
a. Apply bilateral upper extremity restraints. b. Administer haloperidol (Haldol) for agita-tion. c. Close the door to her room to reduce the noise. d. Determine the patients needs.
The number of new cancer cases diagnosed has increased steadily since 1900 . The nurse explains to a client that one of the reasons for this increase is that
a. cancer is related to most birth defects. b. many false-positive cancer results are reported. c. people who live longer are less prone to cancer. d. statistical analysis and reporting are more accurate.
According to the psychoanalytic paradigm, a nurse recognizes that a client who experiences excessive and inappropriate guilt is likely to have problems with his or her:
A) Superego. B) Ego. C) Id. D) Defense mechanisms.