The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following?
1. Ortolani maneuver
2. Palmar grasping reflex
3. Clavicle
4. Tonic neck reflex
3
Explanation: 3. When the Moro reflex is elicited, the newborn straightens arms and hands outward while the knees flex. Slowly the arms return to the chest, as in an embrace. If this response is not elicited, the nurse assesses the clavicle for a possible fracture.
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The nurse is developing a care plan for a patient who's at risk for ineffective coping due to the effects of chronic illness. Which factor provides the best evidence that the patient is at risk for difficulty in coping?
A) Poor sleeping habits B) Lack of social support C) Adverse drug effects D) Presence of panic disorder
Which of the following is likely to result in damage to the client's skin? (Select all that apply.)
1. Dry shaving a client in preparation for discharge 2. Removing the tape when discontinuing a heparin lock 3. Frequently positioning the client on her favorite right side 4. Applying moisturizing lotion on the heels of a diabetic client 5. Elevating the bed to 85 degrees so the client can easily watch a movie on TV 6. Waiting until the mechanical lift is available to transfer an immobile client
The nurse questions the prescription of orlistat (Alli) for which client?
1. A 58-year-old woman with long-term asthma 2. A 48-year-old woman with hypothyroidism 3. A 22-year-old man with borderline type II diabetes 4. A 62-year-old man with presbyopia
A patient has dilated pupils, respiratory rate of six per minute, and seizure activity. What should the nurse prepare to administer to this patient?
A. Ammonium chloride B. Activated charcoal C. Naloxone (Narcan) D. Diazepam (Valium)