The nurse is caring for a client with chronic kidney disease who has developed uremia. Which assessment finding does the nurse correlate with this problem?
a. Decreased breath sounds
b. Foul-smelling urine
c. Heart rate of 50 beats/min
d. Respiratory rate of 40 breaths/min
D
A client with uremia will also have metabolic acidosis. With severe metabolic acidosis, the client will develop hyperventilation, or Kussmaul respirations, as the body attempts to compensate for the falling pH. The other manifestations would not be associated with acidosis.
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A new mother is concerned that her 3-year-old child is not adapting well to the birth of a new sibling 1 month ago. What suggestion can the nurse provide to best help this mother?
A. Explain to the child that she will always have a special bond with the new sibling. B. Give the 3-year-old a special chore that only she does to help her mom. C. Promise the 3-year-old that she can have a pet if she is good to her new sibling. D. Tell the child she will need to get used to having a new baby in the house.
In the course of a focused neurologic assessment, the nurse is palpating the patient's major muscle groups at rest and during passive movement
Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A) Muscle dexterity B) Muscle tone C) Motor symmetry D) Deep tendon reflexes
On the nurse's second visit to the family, further assessment allowed creation of a family map. What would such a map help the nurse understand?
A. Communicator and leader who speaks for the family B. Genogram or family tree of the family C. Geographic location of neighborhood resources for the family D. Organization such as roles, interaction patterns, and relationships within the family
Ketones are present in a urine specimen of a client in the beginning phases of labor. What should the nurse consider as the reason for this laboratory finding? Select all that apply
1. Edema 2. Vomiting 3. Dehydration 4. Preeclampsia 5. Insulin resistance