Your assessment of a pregnant teenager includes assessing for sexually transmitted diseases (STDs). This is an example of assessing for which type of needs?
1. physical needs
2. psychological needs
3. social needs
4. basic needs
ANS: 1
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When choosing a site for an IM injection in a young child, the nurse understands that the deltoid injection site is rarely used because:
a. this muscle is not fully developed until adolescence. b. it is more difficult to restrain the child when using the deltoid site. c. the child may become more upset when watching the nurse use this site. d. all of these factors are rationales for not using this site.
The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse assists the client into which of the following positions?
1. Left-sided lateral Sims position 2. Right-sided lateral Sims position 3. Left side-lying, with the head of the bed elevated 45 degrees 4. Right side-lying, with the head of the bed elevated 45 degrees
A nurse has delegated the collection of vital signs, including blood pressure readings, to two unlicensed assistive personnel. What is the nurse's responsibility for the delegated care?
A. The nurse is not responsible for these vital signs. B. The nurse is responsible for re-measuring all the vital signs. C. The nurse is accountable for the care that was delegated. D. The nurse is not accountable for these vital signs.
The nurse is conducting a physical examination of the skin, hair, and nails. Why should the nurse note the age of the patient?
A. It reminds the nurse that scaly, dry skin is more common in young adults. B. It validates that skin changes in the older population are pathologic. C. It alerts the nurse to expect age-related changes. D. It reinforces the concept that age is the most significant risk factor for cancer.