The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention?
1. Eyes are covered, no clothing on, diaper in place
2. Axillary temperature 99.7°F
3. Infant removed from the isolette for breastfeeding
4. Loose bowel movement
2
Explanation: 2. Temperature assessment is indicated to detect hypothermia or hyperthermia. Normal temperature ranges are 97.7°F-98.6°F. Vital signs should be monitored every 4 hours with axillary temperatures.
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A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a friend who just died from cancer of the prostate. He is concerned this will happen to him. How should the nurse respond?
a. "The swelling in your prostate is only temporary and will go away." b. "We will treat you with chemotherapy so we can control the cancer." c. "It would be very unusual for a man your age to have cancer of the prostate." d. "The enlargement of your prostate is caused by hormonal changes, and not cancer."
The use of restraints for a hospitalized client is indicated in which of these situations?
a. when close observation and supervision of the client cannot be provided by nursing personnel b. when all other interventions have been tried first c. when other disciplines prefer not to deal with the client's underlying problem d. when only jacket restraints are indicated
While caring for a patient admitted with chest pain, the nurse recognizes that what factor places the patient at the highest risk for heart disease?
1. overweight and carries the weight around the waist 2. mother died at age 70 of an acute myocardial infarction 3. a single mother of four young children with a low income 4. has a desk job and works long hours
A nurse is preparing a teaching plan for a woman who is pregnant for the first time. Which of the following would the nurse incorporate into the teaching plan to foster the client's learning? (Select all that apply.)
A) Teach "survival skills" first B) Use simple, nonmedical language C) Refrain from using a hands-on approach D) Avoid repeating information E) Use visual materials such as photos and videos