The nurse assesses a pregnant woman for pregnancy-induced hypertension. What is the first sign of fluid retention suggestive of this complication?
a. Abdominal enlargement
b. Facial swelling
c. Sudden weight gain
d. Swelling of the feet and ankles
ANS: C
Sudden, excessive weight gain is the first sign of fluid retention; facial swelling and swelling of the feet, legs, and hands follow weight gain.
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A client who is 36 years old, weighs 200 pounds, is monogamous, and does not smoke desires birth control. The nurse understands that which of the following is inappropriate for this client?
1. Intrauterine device 2. Vaginal sponge 3. Combined oral contraceptives 4. Transdermal hormonal contraception
The nurse is instructing a patient on testicular self-examination. What information should the nurse include in this teaching?
1. Any painful lump should be reported immediately. 2. Tenderness of the scrotal sac contents should be reported. 3. Most men have one testicle that is significantly larger than the other. 4. It is best to do the examination upon arising on the designated day.
When a client who has received ketamine HCl is admitted following surgery, the nurse should:
a. provide tactile stimulation to prevent respiratory depression. b. place the client in a quiet area with as little stimulation as possible. c. administer dantrolene, the antidote for ketamine toxicity. d. not activate any special precautions or actions.
At the basic level of practice of psychiatric nursing, the nurse is qualified to:
a. diagnose mental disorders using the DSM-IV b. assist clients to regain or improve coping c. treat mental disorders d. prescribe simple medications under supervision