The nurse is working in a clinic performing assessments on well newborn infants. A 3-month-old child that the nurse has weighed and measured falls below the 5th percentile
Which of the following does the nurse suspect is the reason for the slow weight gain? 1. The infant eats an appropriate amount each day.
2. The parents are Asian American.
3. The child sleeps the whole night through.
4. The parents socialize two nights a week.
2. The parents are Asian American.
Rationale: An Asian American child is apt to fall below the 5th percentile as Asian American children are normally smaller than other American children, and growth charts are based on American averages. If the infant is eating appropriately and is growing, there is no problem. Three-month-old infants usually do sleep the whole night. The parents' socializing two nights a week is not a problem as long as the child is cared for.
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A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding."
During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with: a. Heart failure. b. Aortic stenosis. c. Pulmonary edema. d. Mitral regurgitation.
The nurse is assessing the cardiovascular status of an elderly client. Which of the following changes is expected to occur as a natural part of the aging process?
a. Increased elasticity of heart muscle b. Increase in systolic blood pressure c. Increase in arterial diameter d. Thinning of venous walls
A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse?
a. Obtain a medical order. b. Sedate the client. c. Get written consent. d. Notify the family.
Which statement most accurately reflects the status of continuing competence in nursing?
A) Professional organizations are actively implementing continuing competence mandates. B) State regulatory agencies should be the ones to monitor competency. C) No national standards exist for defining and measuring competency. D) A current consensus has been reached for measuring competency.