A nurse is assessing the fontanels of a crying newborn and notes that posterior fontanel pulsates and briefly bulges. What do these findings indicate?
A) Increased intracranial pressure
B) Overhydration
C) Dehydration
D) These are normal findings.
D
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The laboring client presses the call light and reports that her water has just broken. The nurse's first action would be to:
1. Check fetal heart tones. 2. Encourage the mother to go for a walk. 3. Change bed linen. 4. Call the physician.
After auscultating a coarse low-pitched sonorous rattling in the left lower lobe, the nurse is concerned that the patient may be developing:
a. an accumulation of secretions in the larger air passages. b. narrowing in the lower lobe of the lung. c. irritation in the pleurae. d. crackles in the left lower lobe.
A client shows a nurse a piece of artwork that took 3 days to create. How will this achievement improve the client's self-esteem?
A. By providing a framework for assertive behavior B. By providing an expression of feelings and a sense of competence and pride C. By providing a positive perception of body image D. By providing appropriate boundaries for relationship establishment
Which delegated task should the charge nurse working on a unit with team nursing question?
1. The nurse asked the nursing assistant to assist the client out of bed when the client asked to go to the bathroom. 2. The nursing assistant is asked to fill the water pitchers for all clients on the unit. 3. The unit secretary is asked to take a client to Radiology after the orders are put into the computer. 4. The nurse who is on the phone with a health care provider asked the unit secretary to take a message from another provider calling with client orders.