A nurse is caring for a client who is 2 years old. At this developmental stage, this client's fearfulness would most likely be related to which condition?
A) Loud noises
B) Strangers and darkness
C) Death
D) Social rejection
B
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A nurse is assessing pain in an older adult. What action by the nurse is best?
a. Ask only "yes-or-no" questions so the client doesn't get too tired. b. Give the client a picture of the pain scale and come back later. c. Question the client about new pain only, not normal pain from aging. d. Sit down, ask one question at a time, and allow the client to answer.
A woman with a history of two stillbirths is in the active phase of the first stage of labor in the high-risk OB unit. How often should the nurse anticipate monitoring fetal heart tones (FHTs)?
A. Continuously B. Every 5 minutes C. Every 15 minutes D. Every 30 minutes
Assessment of a client in the home reveals that his services will be paid by a government source. Which of the following would be a possible source of payment?
A) Insurance company B) Health maintenance organization C) Medicare D) Preferred provider organization
An 86 year old woman had an anterior and posterior colporrhaphy (A & P repair) several days ago. Her retention catheter was removed 8 hours ago. Which assessment finding requires that you act most rapidly?
a. The oral temperature is 100.7 F (38.2 C) b. The abdomen is firm and tender to palpation above the symphysis pubis. c. Breath sounds are decreased, with fine crackles audible at both bases d. The apical pulse is 86 beats/min and slightly irregular