To evaluate an individual's progression through puberty, which assessment tool would be used during the assessment phase of the nursing process?
a. Bishop score
b. Tanner staging
c. Braden score
d. SOFA score
ANS: B
Tanner staging provides a gender-based criteria approach that defines the physical findings of primary and secondary sex characteristics for children and adolescents during puberty. The Bishop score would be used to evaluate whether a labor client is ready for the induction of labor. The Braden score provides documentation of skin condition relative to potential breakdown and/or complications. The SOFA score is used to evaluate critical care clients who are at risk to develop SIRS or MODS.
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The nurse is teaching the parents of a child with idiopathic rheumatoid arthritis about chronic pain. Which statement by the parent indicates teaching has been successful?
1. "When children have chronic pain, they may not have the same behavior as those in acute pain." 2. "It is associated with a single event." 3. "Chronic pain can be managed successfully with NSAIDs." 4. "It is sudden and of short duration."
Which of the following assessment findings on an African American client should be reported to the primary nurse?
A) red splinter hemorrhages on the nails B) keloid formation over an appendectomy scar C) pigmented bands on the fingernails D) a pustule on the right hand
For the client with cirrhosis, what nursing intervention(s) would be most appropriate to control fluid accumulation in the abdominal cavity?
A. Monitoring intake and output B. Providing a low-sodium diet C. Increasing PO fluid intake D. Weighing the client daily
Which of the following statements reflect the principles of sterile technique?
A. The edge of a sterile field and a border 1 inch inward is unsterile. B. If a package is not labeled as sterile, it should be considered unsterile. C. Sterile objects that come in contact with unsterile objects are to be considered contaminated. D. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched. E. When a sterile field becomes wet, it remains sterile as long as the items on the field are not touched. F. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated.