One of the first signs of overwhelming sepsis in a child with burn injuries is:
a. Seizures. c. Disorientation.
b. Bradycardia. d. Decreased blood pressure.
ANS: C
Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial manifestations of overwhelming sepsis.
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One way for the manager to help improve communication between nurses of different cultures is to:
a. teach nurses American ways c. provide cultural workshops b. allow only English speaking d. teach American slang terms
An older client is having visual field testing. The nurse should monitor the client for:
1. dizziness. 2. fatigue. 3. vomiting. 4. pain.
The nurse is preparing to measure the head circumference of a 6-month-old child. How should the nurse make this measurement?
A) From the hairline in front to the hairline in back B) From the center of the forehead to the base of the occiput C) Above the eyebrows through the prominent part of the occiput D) From the middle of the forehead through the parietal prominences
A client is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes, and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations
What would the nurse's initial response be? 1. Perform a vaginal exam 2. Notify the physician 3. Place the client in a left lateral position 4. Administer oxygen at 2 L per nasal cannula