The nurse educator is describing the different kinds of abruptio placentae to a group of students, explaining that in a complete abruptio placentae:
1. Separation begins at the periphery of the placenta.
2. The placenta separates centrally, and there can be concealed bleeding.
3. There is massive vaginal bleeding in the presence of almost total separation.
4. Blood passes between the fetal membranes and the uterine wall, and escapes vaginally.
3
Rationale 1: This describes a marginal separation of the placenta.
Rationale 2: This describes a central separation of the placenta.
Rationale 3: This describes a complete separation of the placenta.
Rationale 4: This describes a marginal separation of the placenta.
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A client with metabolic acidosis has a nursing diagnosis of Decreased Cardiac Output. The nurse should monitor the client frequently by checking:
1. sleep patterns. 2. capillary refill. 3. paresthesia. 4. hyperactive reflexes.
A client is moving into a long-term care facility. During the data collection, the nurse is collecting information concerning his visual acuity. The nurse notes the client is wearing glasses
When performing the assessment, what actions by the nurse are most appropriate? A) Ask the client to remove the glasses during the assessment. B) Allow the client to choose whether or not to remove the glasses during the assessment. C) If the client reports wearing the glasses more than 25% of the time, the glasses should be worn during the assessment. D) Ask the client to wear the glasses.
Which statement made by a resident in a long-term care facility should lead the nurse to conclude a positive resolution of the developmental task of old age?
a. "I love my children. I could have done more for them." b. "I am too young to be in a place like this." c. "I miss my friends and wife. I'm ready to go." d. "I've enjoyed the ride!"
The end of shift report is vital for the coordination of patient care. Which of these statements would require an intervention if overheard by the charge nurse during report?
a. "Mr. Smith is quite afraid of the outcome of his procedure today. I had to give him an anti-anxiety medication.". b. "Mr. Smith is quite afraid of the outcome of his procedure today. I called his wife to come in early.". c. "Mr. Smith is quite afraid of the outcome of his procedure today. I called the chaplain to see him and his wife today.". d. "Mr. Smith is quite afraid of the outcome of his procedure today. I was in the room most of the day.".