In the client with Crohn's disease experiencing severe diarrhea, what should the nurse monitor for as the priority assessment?
A. Cardiac dysrhythmias
B. Skin irritation
C. Anorexia
D. Anemia
A
Although the client with severe diarrhea may experience skin irritation and anemia, the client is most at risk of cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have electrolyte levels monitored, and electrolyte replacement may be necessary.
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The nurse makes a conscious decision to not believe that one's own ethnic beliefs, customs and attitudes are correct and superior. This nurse is consciously avoiding:
a. racism. b. stereotyping. c. ethnocentrism. d. acculturation.
The nurse is able to percuss a dull tone over a client's bladder after the client has voided 300 ml of urine. The nurse would conclude which of the following is most likely the cause of this finding?
1. This is a normal finding 2. Possible urinary tract infection 3. This is a sign of prostate enlargement 4. Probable urinary retention
In caring for the patient's spiritual needs, the nurse understands that
a. Establishing presence is part of the art of nursing. b. Presence involves "doing for" the patient. c. A caring presence involves listening to the patient's wishes only. d. The nurse must use her expertise to make decisions for the patient.
Which child would the nurse suspect as having a developmental delay?
A) A 5-month-old who does not sit unsupported B) An 11-month-old who does not pull himself to a standing position. C) A 3-month-old who cannot grasp an object voluntarily. D) A 12-month-old who cannot build a tower of 8 blocks.