Your 10-year-old client has been sexually abused by her father. She talks about her anger at God for letting this happen. What nursing diagnosis would be most appropriate?
1. Ineffective coping
2. Readiness for enhanced spiritual well-being
3. Risk for spiritual distress
4. Spiritual distress
ANS: 4
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The nurse is examining the glans and knows which finding is normal for this area?
a. The meatus may have a slight discharge when the glans is compressed. b. Hair is without pest inhabitants. c. The skin is wrinkled and without lesions. d. Smegma may be present under the foreskin of an uncircumcised male.
In which situation might surgery be delayed?
a. The patient has taken Dilantin today. b. An illegible signature is on the consent form.. c. The patient is still taking anticoagulants. d. The admission office is unable to confirm insurance coverage.
Many medications are available to control nausea and vomiting without oversedating the patient. At what point should a nurse normally administer antiemetics to a surgical patient?
A) Upon admission from PACU B) When the patient reports that he or she will soon vomit C) At the patient's first report of nausea D) When nonpharmacologic interventions are unsuccessful
When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. Why is this preferable to methods used for adults?
a. It is accurate even when the forehead is covered with hair. b. It is not affected by skin moisture. c. It reflects rapid changes in radiant temperature. d. There is no risk of injury to patient or nurse.