A nurse is working in a critical care unit where the focus is on primary care nursing. The nurse demonstrates understanding of primary care nursing when
1. Asking an unlicensed assistant to give a bed bath.
2. Asking another nurse to call the physician for orders.
3. Providing all aspects of nursing care for assigned patients.
4. Instructing the nursing assistant to take the patient's vital signs.
ANS: 3
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A 12-year-old child is injured in a bicycle accident. When considering the possibility of renal trauma, the nurse should consider what factor?
a. Flank pain rarely occurs in children with renal injuries. b. Few nonpenetrating injuries cause renal trauma in children. c. Kidneys are immobile, well protected, and rarely injured in children. d. The amount of hematuria is not a reliable indicator of the seriousness of renal injury.
The nurse is working with a client to develop an expected outcome for the nursing diagnosis Disturbed Sleep Pattern, difficulty staying asleep related to anxiety secondary to multiple life stressors. Which expected outcome would be most applicable to this client's situation? The client will:
A) Report getting sufficient sleep to provide energy for daily activities. B) Manifest less anxiety after taking prescribed medications. C) Sleep at least 8 hours each night. D) List three positive coping mechanisms for anxiety relief.
A patient has just returned to the nursing unit after having a renal biopsy. Which intervention is most important to include in the patient's nursing care plan?
a. Keep the patient NPO for the first 4 hours after the procedure. b. Instruct the patient to avoid laughing and use a pillow to splint when sneezing. c. Report hematuria immediately. d. Teach the patient about the importance of limiting fluid intake.
An inspection of the lower extremities is being performed. The presence of arterial insufficiency is suspected when the nurse observes:
A. Increased hair growth B. Cooler skin temperatures C. Marked edema D. Brown pigmentation