The nurse is caring for a client who could be at risk for uterine rupture. The nurse is monitoring the fetus closely for which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Late decelerations
2. Bradycardia
3. Loss of ability to determine fetal station
4. Tachycardia
5. Early decelerations
1, 2, 3
Explanation: 1. Late decelerations could be seen with uterine rupture.
2. Bradycardia is seen if there is uterine rupture.
3. The uterus is not holding the fetus in place anymore if the uterus ruptures.
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What may provide a rationale for the different perceptions of pain? A) Endorphin levels may vary between patients, affecting the perception of pain. B) One of the patients is exaggerating his sense of pain. C) The patients are likely experiencing a variance in vasoconstriction. D) One of the patients may be experiencing opiate tolerance.
A nurse who is using a 24-hour recall method for obtaining data about a client's dietary intake would be aware that which of the following is true?
1. Most clients accurately recall the exact amounts of various foods eaten. 2. The previous day's intake may not represent the usual intake. 3. Virtually all clients provide thorough and accurate information. 4. Clients have a tendency to overestimate intake as the portion size increases.
A nurse must display understanding of the mental implications of a client on isolation precautions when planning care to control the risk of:
1. Denial 2. Aggression 3. Regression 4. Isolation
The psychiatric nurse is caring for a 15-year-old girl who has been hospitalized for bipolar disorder. The client tells the nurse that she had her hair styled just like her young math teacher, whom she admires. Which defense mechanism should the nurse recognize that the client is using?
A. Projection B. Regression C. Identification D. Intellectualization