The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements
This care is most appropriate for an infant born with: 1. Oomphalocele.
2. Gastroschisis.
3. Diaphragmatic hernia.
4. Myelomeningocele.
4
Rationale 1: Oomphalocele is a herniation of abdominal contents into the base of the umbilical cord. Positioning on the abdomen would be detrimental.
Rationale 2: Gastroschisis is a full-thickness defect of the abdominal wall, resulting in the abdominal organs' being located on the outside of the body. Positioning on the abdomen would be detrimental.
Rationale 3: Diaphragmatic hernia is incomplete formation of the diaphragm, resulting in the bowel and sometimes the stomach's extending upward through the defect and into the chest cavity.
Rationale 4: Myelomeningocele is a neural tube defect in which the meninges and spinal cord are exposed. Meticulous cleaning of the perineum helps prevent infection. The infant is positioned prone to prevent pressure on the defect. Hydrocephalus often is present.
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A patient with an intense fear of cats reports that after 2 weeks of therapy, she no longer sweats or becomes nauseated when she sees a cat on television but still cannot be in the same room with a cat
The nurse would interpret this change as meaning that the patient: a. is responding to therapy, and the current treatment can continue. b. is responding, but slowly, and her treatment plan should be changed. c. has unrealistic expectations and will always need to avoid cats. d. is deteriorating and requires medication and more intensive therapy.
Which documentation indicates that the treatment plan for a patient with acute mania was effective?
a. "Converses without interrupting; clothing matched; participates in activities.". b. "Irritable; suggestible; distractible; napped for 10 minutes in afternoon.". c. "Attention span 1 to 3 minutes; journals frequently about unit activities.". d. "Heavy makeup; seductive toward staff; pressured speech.".
Mrs. Lopez has a severe visual impairment and has been hospitalized twice for falls occurring at home. Which of the following might be an appropriate nursing diagnosis for her?
a. Ineffective health maintenance related to knowledge deficit b. Ineffective health maintenance related to safety hazards c. Potential risk for further development d. Potential risk for infection
At 9:15 AM the nurse repeatedly instructs the patient to remain in bed. At 9:30 the nurse enters the patient's room, finds the patient on the floor, and hears the patient say, "I need pain medi-cine."
Which should the nurse do to document this event? a. Label the late entry using the time of 9:15 AM b. Enclose the patient statement within quo-tations c. Document completion of an incident re-port d. Record medication before its administra-tion