The nurse is explaining the importance of handwashing after using the toilet to parents of young children. Which is the most important reason for this practice?
1. Children do not like to have dirty hands.
2. Handwashing is the main way to limit the transmission of disease.
3. Not all bathrooms are clean.
4. Children's immune systems are not fully developed.
2
Rationale:
1. This is not a reason for washing hands after using the toilet.
2. The fecal–oral and respiratory routes are the most common sources of transmission in children.
3. Children usually do not wash their hands after toileting unless they are closely supervised.
4. Underdeveloped immune systems will not transmit disease.
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An older woman falls down at church and immediately complains of severe pain in her left hip. Which observation is recognized as the cardinal sign of a fractured hip?
a. Shortened left leg compared with the right b. Downward curled toes c. Internal rotation of the left leg d. Hematoma on the left hip
For the past three exchanges, a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) has retained between 250 and 400 mL with each exchange. He has no urine output and has not moved his bowels in 3 days
The returned CAPD fluid is clear. Select the most appropri-ate action by the nurse at this time. a. Increase the glucose concentration of the fluid to pull off more fluid. b. Cap the catheter and notify the physician. c. Evaluate the patient for possible constipa-tion. d. Skip the next exchange and allow the fluid to drain.
A teenager commits suicide after revealing to his parents that he is a homosexual. Which information would be appropriate for a nurse to share with the family at this time?
A) Funeral arrangement information B) Education on the grieving process C) Medication evaluation referrals D) Gay and lesbian support group times and locations
The nurse is assessing a newborn's eyes. Which of the following would the nurse identify as normal? (Select all that apply.)
A) Slow blink response B) Able to track object to midline C) Transient deviation of the eyes D) Involuntary repetitive eye movement E) Absent red reflex