Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as indicating which of the following?
A) A good time to initiate breast-feeding
B) The period of decreased responsiveness preceding sleep
C) The need to be alert for gagging and vomiting
D) Evidence that the newborn is becoming chilled
A
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While assessing the development of a nine-month-old infant, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. The nurse is trying to determine whether the infant has developed:
1. Transductive reasoning 2. Conservation 3. Centration 4. Object permanence
A nurse is creating a plan of care for a 68-year-old woman with a recent diagnosis of unstable angina and new prescription for nitroglycerin
Which of the following nursing diagnoses should the nurse prioritize in the planning of this patient's care? A) Incontinence, Functional, related to adverse effects of drug therapy B) Risk for Fluid Volume Deficit related to adverse effects of drug therapy C) Confusion, Acute, related to adverse effects of drug therapy D) Acute Pain, Headache, related to adverse effects of drug therapy
A client is prescribed clonidine as a transdermal patch. After instructing the client about this drug, the nurse determines that the teaching was successful when the client states that the patch should remain in place for how long?
A) 24 hours B) 3 days C) 7 days D) 2 weeks
A client with severe malnutrition has pedal edema and ascites. The nurse notes that the weight is unchanged for the last 2 days. The most appropriate action by the nurse is to
a. ask the assistive personnel to re-weigh the client. b. assess vital signs, level of consciousness, and urine output. c. call the physician to request IV diuretics. d. have biomedical engineering check the scale.