The nurse understands that—compared with a mature woman—the pregnant adolescent is at greater risk for:
a. Thrombophlebitis
b. Excessive weight gain
c. Respiratory tract infection
d. Pregnancy-induced hypertension
ANS: D
Pregnant adolescents are at greater risk for pregnancy-induced hypertension, anemia, nutritional deficiencies, and urinary tract infections.
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Many clients have misconceptions regarding assessment and treatment of pain. Which statement by the client indicates the need for additional clarification?
1. "If I don't report pain, it does not necessarily mean that I don't have any pain." 2. "I can have a back rub and think of relaxing thoughts to help decrease the amount of medication I take for pain." 3. "The best judge of the existence and severity of pain is the nurse who is taking care of me." 4. "I will be asked to rate my pain on a predetermined scale."
While the client sleeps, the nurse notes that the client's respirations periodically stop. This finding would be documented as:
1. Tachypnea. 2. Bradypnea. 3. Apnea. 4. Atelectasis.
The nurse is reviewing concepts of safe medication preparation and administration with a group of nursing students. Which statement should the nurse include during the review?
a. Use sterile technique for most nonparen-teral medications. b. Administer the medication prepared by the medication nurse. c. Leave the medication on the meal tray for the patient to take. d. Verify medication dosage is within a safe dosage range.
Which intervention is most appropriate for the nursing diagnostic statement, Impaired skin integrity related to shearing forces?
a. Administer pain medication every 4 hours as needed. b. Perform the ordered dressing change twice daily. c. Do not document the wound appearance in the chart. d. Keep the bed side rails up at all times.