The advanced practice nurse refers the client to physical therapy for further rehabilitation. This is an example of which of the ANA standards of practice?
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
Correct Answer: 4
Rationale: Standard 5: Implementation includes prescriptive authority and treatment, which would include a referral for further treatment and therapy in accordance with state and federal laws and regulations. Assessment is data collection. Diagnosis analyzes the assessment data. Planning prescribes strategies and alternatives to reach the expected goals.
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A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen) for prevention of anaphylactic shock
The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate? A) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." B) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." C) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." D) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure."
Which finding from your examination of a 2-year-old child's thorax and lungs is abnormal?
a. barrel chest b. bronchovesicular sounds heard throughout the peripheral lung fields c. cough and wheezing d. diaphragmatic excursion of two intercostal spaces
A client experiencing paranoid delusion states, "They are conspiring against me; they're after me all night." Which of the following responses by the nurse would be the MOST empathetic?
a. "That sounds frightening." b. "You can't sleep?" c. "This cannot be true." d. "You are having a delusion."
Temperature, dryness, or a rash are observations that you could make regarding the ____________________ system.
Fill in the blank(s) with the appropriate word(s).