Upon inspection, the nurse notes that the patient has a barrel chest. What is the normal anteroposterior (AP)-to-lateral chest ratio?
1) 1:1
2) 1:2
3) 1:3
4) 1:4
ANS: 2
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The nurse has admitted a child with a ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?
1. Hypothermia related to decreased metabolic state 2. Acute pain related to the effects of a congenital heart defect 3. Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect 4. Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow
The student nurse is providing skilled care for a palliative care client. The client is bedbound, requiring skin care during bathing, oral care, and every 2 hours positioning
Which NCLEX-PN test category would the student anticipate finding questions related to this clinical care situation? A) Health promotion and maintenance B) Psychosocial integrity C) Physiologic integrity D) Safe and effective care environment
A waveform that appears to _________ is one that appears abnormally rapid and sometimes erratic.?
A) flutter B) spike C) fibrillate D) curve
An older adult patient who recently lost her husband is admitted for surgery. The nurse notices that the patient is experiencing an alteration in psychosocial development when the patient:
A. accepts her own limits. B. voices concerns about the upcoming surgery. C. expresses her opinions about the quality of care. D. demands unnecessary assistance from her daughter.