When collecting data on a child with hydrocephalus, in addition
to the child likely having a large head at birth and rapid head growth, which sign should the nurse recognize as a manifestation of this disorder?
A) Posterior fontanelle bulging and tense
B) Eyes appear to be pushed downward
C) Hands short with curved fingers
D) Neck area is thickened and strong
Ans: B
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A client with bipolar disorder who relapsed after discontinuing lithium has lost 5 pounds in the 4
days since hospitalization. The nursing diagnosis of "imbalanced nutrition: less than body requirements related to caloric intake insufficient to balance energy expenditure associated with hyperactivity" has been established. The short-term indicator that should be used to evaluate progress toward the desired outcome of "intake will be sufficient to maintain weight within normal range for height and age" is a. while in the acutely manic state, the client will drink 8 ounces of high-calorie, high-protein drink hourly throughout the day. b. the client will display consistently nonviolent behavior toward others on the unit within 1 week with the aid of medications and nursing interventions. c. the client will have competent medical assistance and legal protection when signing any document regarding personal matters during hospitalization. d. the client will consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.
The nursing instructor is talking about anticoagulant therapy. The instructor explains that when administering warfarin (Coumadin) to a client with deep vein thrombophlebitis, the nurse monitors the PTT, PT , INR, and hematocrit
Which laboratory value would the instructor teach the class that indicate warfarin is at therapeutic levels? A) Partial thromboplastin time (PTT) 1½ to 2 times the control B) Prothrombin time (PT) 1½ to 2 times the control C) International normalized ratio (INR) of 3 to 4 D) Hematocrit of 32%
The nurse teaches a patient about the medication orlistat (Xenical). Which patient statement indicates the need for additional teaching?
1. "I should take this medication 30 minutes before eating." 2. "This medication will reduce the amount of fat my body absorbs." 3. "I will need to take supplements of vitamins A, D, E, and K daily." 4. "A low-calorie diet will need to be followed."
A school nurse is teaching a class of adolescents about healthy behaviors. Which of the following activities include as a means for preventing anxiety and depression when they are middle-aged adults?
A) Restricting their sugar and fat intake B) Refraining from smoking or doing drugs C) Engaging in physical activity and exercise D) Becoming active in local church activities