A nursing instructor is demonstrating an assessment on a newborn for the nursing students, and is using the Ballard gestational assessment tool
The nurse explains that which of the following tests should be performed after the first hour of birth? A. Arm recoil
B. Square window sign
C. Scarf sign
D. Popliteal angle
A
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A nurse is taking the history of a client and suspects that the client has been sexually abused. Which question will prompt a response that will aid the nurse in making an accurate assessment?
1. "Do you like to dress in provocative outfits?" 2. "Has anyone touched you in a way that made you feel uneasy or uncomfortable?" 3. "Do you have any bruises anywhere on your body?" 4. "How is your relationship with your parents and older siblings?"
Which statement made by a male patient with an SCI could be assessed as a positive adaptation to the nursing diagnosis of "Sexual dysfunction, related to altered body function"?
a. "I know I will never have a sexual rela-tionship again." b. "I need some suggestions as to how to di-rect my sexual energy into gardening or painting . . . or just anything." c. "Can you arrange an appointment with a sex counselor so I can begin to examine alternative methods of sexual activity?" d. "I think that after a while I will be able to have sexual relationships just like I had before my accident."
A nurse is providing an educational session on vaccines to a group of older adults. The nurse is discussing the zoster vaccine (Zostavax). Which of the following information should the nurse include in the education?
a. Zostavax should only be given to individ-uals who have never had an episode of herpes zoster (HZ) b. Zostavax is recommended for all individ-uals over age 60 that have no contraindi-cations to the vaccine c. Zostavax should not be given to anyone with a chronic cardiac or respiratory con-dition d. Zostavax will always prevent an individu-al from developing Herpes Zoster
A patient who has been on methotrexate
therapy is experiencing mild pain. The patient is asking for aspirin for the pain. The nurse recognizes that which of these is true in this situation? a. The aspirin will aggravate diarrhea. b. The aspirin will masks signs of infection. c. Aspirin can lead to methotrexate toxicity. d. The aspirin will cause no problems for the patient on methotrexate.